The pelvic exam is a standard part of women’s gynecologic checkup, but a new review by the American College of Physicians shows that for healthy women it is likely doing more harm than good, causing the doctors’ group to issue a new guideline that advises against it.
The new guideline, plus a report on the supporting evidence review, are published in the Annals of Internal Medicine, along with an editorial comment.
Dr. Linda Humphrey, member of the American College of Physicians (ACP) Clinical Practice Guidelines Committee and co-author of the new guideline, says:
“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost.”
She notes that the new guideline only applies to pelvic exams – it does not apply to Pap smear screening for cervical cancer, which the ACP recommends should be restricted to visual inspection of the cervix and taking cervical swabs to test for cancer and in some cases human papillomavirus (HPV). This does not need to include a bimanual exam says the doctors’ group.
For many decades, the pelvic exam has been a regular part of preventive care for women in the US, where 63.4 million exams were performed in 2008.
But some have begun to question whether this standard part of a woman’s regular checkup is medically justified. For instance, in December 2012, Medical News Today reported how, after conducting a nationwide survey, a team at University of California – San Francisco (UCSF) questioned the reasons for routine pelvic exams.
In their research, the UCSF team found that many physicians mistakenly believed the pelvic exam was important in screening for ovarian cancer. Their survey of obstetricians and gynecologists around the US also showed that doctors continued to perform the exam in part because women had come to expect it.
But in their latest analysis of evidence to date, which drew on 52 published studies, the ACP found the routine pelvic exam has a low rate of success as a way to detect gynecologic cancer or infections.
However, in cases where women have symptoms such as abnormal bleeding, pain, urinary problems, sexual dysfunction or vaginal discharge, the pelvic exam is appropriate, says the doctors’ group.
The ACP evidence review found no data to support use of pelvic examination in asymptomatic, average-risk women.
Dr. Molly Cooke, immediate past president of the ACP, and of the body’s Clinical Practice Guidelines Committee, explains the findings show that the “screening pelvic examination exposes adult, asymptomatic, average risk, non-pregnant women to unnecessary and avoidable harms, including anxiety, embarrassment and discomfort, and may even prevent some women from getting needed medical care.”
She also says false positive findings “can lead to unnecessary tests or procedures, adding additional unnecessary costs to the health care system.”
In the accompanying editorial, Dr. George Sawaya and Dr. Vanessa Jacoby of UCSF’s Department of Obstetrics, Gynecology and Reproductive Sciences note that the routine pelvic exam “has come to be more of a ritual than an evidence-based practice.”
“With the current state of evidence,” they add, “clinicians who continue to offer the examination should at least be cognizant about the uncertainty of its benefits and its potential to cause harm through false-positive testing and the cascade of events it prompts.”
The ACP’s new guideline includes advice to help doctors and patients understand the benefits, harms and costs of the pelvic exam.