ABSTRACT & COMMENTARY
Do Patients Need Routine Pelvic Exams?
By Jeffrey T. Jensen, MD, MPH, Editor
A review of the published literature finds no value to the routine screening pelvic examination in asymptomatic non-pregnant women.
Qaseem A, et al. Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161:67-72.
The American College of Physicians (ACP) published this guideline to present the evidence and provide clinical recommendations on the utility of screening pelvic examination for the detection of pathology in asymptomatic, nonpregnant, adult women. Investigators from the Minneapolis Veterans Affairs Health Care System’s Evidence-based Synthesis Program Center conducted a systematic review of the literature to address the utility of the screening pelvic examination in symptomatic women by evaluating the following key questions: 1) How accurate is the exam for detection of cancer (other than cervical), pelvic inflammatory disease, or other benign gynecologic conditions? 2) What are the benefits (reduced mortality and morbidity rates) and harms (overdiagnosis, overtreatment, or diagnostic procedure-related)? and 3) What are the examination-related harms and indirect benefits of performing screening pelvic examinations in asymptomatic women? The investigators conducted a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. They evaluated a variety of outcomes including morbidity, mortality, and harms (i.e., overdiagnosis, overtreatment, and diagnostic procedure-related harms). They also considered patient fear, anxiety, embarrassment, pain, and discomfort. Based on the review of the literature, the ACP recommends against performing screening pelvic examination in asymptomatic, non-pregnant, adult women.
COMMENTARY
This simple study attempts to evaluate the utility of the screening pelvic examination based on the available literature. Although gynecologists raised on a steady diet of routine exams vary in their opinions, most are comfortable with the notion of the annual exam. Many women see this as high-quality health care. Most of us were trained with the belief that the routine exam was needed to adequately screen for cervical cancer and that the pelvic bimanual added additional value in the screening for other pelvic abnormalities. We also understand that the annual exam provides an opportunity for screening and health care counseling for important preventive health issues from hypertension to hyperlipidemia and for contraception counseling.
However, a number of cracks have appeared in the ice over the last 30 years. First and foremost has been the understanding that cervical cancer is a sexually transmitted infection and that highly specific molecular probes can reduce the need for annual pap testing.1 We also have learned that the pelvic exam is not needed prior to a prescription for hormonal contraception.2 Chlamydia is much more prevalent than gonorrhea, and we have urine-based PCR tests that do not require collection of cervical samples.3 Women may prefer this.4 Therefore, the justifications for most pelvic exams in otherwise healthy asymptomatic young women go out the window. Add to this the lack of benefit from detection of an adnexal mass by pelvic exam and you pretty much lose all of the potential benefit from a pelvic on an asymptomatic woman.
But what does the evidence say? To be clear, the authors identified no studies that addressed the diagnostic accuracy of the pelvic examination for a number of benign conditions so could not access the possibility of benefit. To be fair, the absence of evidence does not imply the possibility of benefit, but it does indicate that we should look carefully at what we do. Consider a serious condition like ovarian cancer. The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening randomized controlled trial found no benefit for routine pelvic exams in the diagnosis and prognosis for ovarian cancer.5 The authors of the systematic review found no studies that specifically evaluated the utility of the routine pelvic exam to screen for pelvic inflammatory disease, bacterial vaginosis, or other benign gynecologic conditions. For example, it is possible but unknown whether detection of a benign ovarian mass like a dermoid cyst reduces the risk of subsequent torsion. However, if you think that the screening pelvic might have benefit for detection of other conditions, I invite you to propose and conduct a study.
The ACP recommendations rely heavily on literature that evaluates the displeasure that many women associate with the routine pelvic. While this does represent a barrier to care for many women, I can’t help but feel that investigators may bring their own biases to these studies. My humble opinion is that no one dislikes the routine pelvic examination more than general internists and other primary care providers (PCPs) facing time pressures and inadequate facilities to carry out the exam. Recall the cheers of the PCPs after the WHI findings that hormone replacement therapy was more harmful than good. Internists always disliked the evaluation of HRT-related postmenopausal bleeding.
So should you provide routine pelvic exams? I think we can leave this up to our patients. Many women find value in the routine annual health care exam that includes a pelvic. Others may not need this care. Some clinicians worry about documentation and billing for other health care screening when a pelvic is not done. ACOG released a statement on June 30, 2014, that reiterated the 2104 Committee Opinion which acknowledged that no current scientific evidence supports or refutes an annual pelvic exam for an asymptomatic, low-risk patient. ACOG suggests that "the decision about whether to perform a pelvic examination be a shared decision between health care provider and patient, based on her own individual needs, requests, and preferences." I agree with these recommendations, but it will be interesting to see how insurers view the decision to pay for this exam in the future. For now, at least be aware of the controversy when you recommend and perform this exam.
References
- Dinkelspiel H, et al. Cervical cancer rates after the transition from annual Pap to 3-year HPV and Pap. J Low Genit Tract Dis 2014;18:57-60.
- Harper C, et al. Provision of hormonal contraceptives without a mandatory pelvic examination: The first stop demonstration project. Fam Plann Perspect 2001;33:13-18.
- Meyers DS, et al; U.S. Preventive Services Task Force. Screening for chlamydial infection: An evidence update for the U.S. Preventive Services Task Force. Ann Intern Med 2007;147:135-142.
- Jones HE, et al. Women’s preferences for testing and management of sexually transmitted infections among low-income New York City family planning clients. Int J STD AIDS 2013;24:455-460.
- Buys SS, et al. Effect of screening on ovarian cancer mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011;305:2295-2303.
