EXECUTIVE SUMMARY
The U.S. Preventive Services Task Force has found insufficient evidence to recommend for or against performing pelvic exams in asymptomatic, nonpregnant adult women. Its recommendation statement and evidence review are out for comment.
- The draft statement applies to women ages 18 and older who do not have any signs or symptoms of gynecologic conditions, are not at increased risk for these conditions, and who are not pregnant. This preliminary statement does not address screening for cervical cancer, chlamydia, and gonorrhea, which have been addressed previously by the Task Force.
- The American College Of Obstetricians And Gynecologists Recommends Annual Pelvic Examinations For Patients 21 Years Of Age Or Older.
The United States Preventive Services Task Force has found insufficient evidence to recommend for or against performing pelvic exams in asymptomatic, nonpregnant adult women. While its recommendation statement and evidence review are out for comment, what will be the impact of its final guidance?
For the first time, the independent volunteer panel of national experts has reviewed the evidence on screening for gynecologic conditions with pelvic examination. The draft statement applies to women ages 18 years old and older who do not have any signs or symptoms of gynecologic conditions, are not at increased risk for these conditions, and who are not pregnant. This preliminary statement does not address screening for cervical cancer, chlamydia, and gonorrhea, which have been addressed previously by the Task Force.
In a prepared statement, task member Francisco García, MD, MPH, who serves as director of the Pima County Health Department in Tucson, said that the panel is calling for more research to better understand the benefits and harms of performing screening pelvic exams in women without any complaints or symptoms.
Task Force member Maureen Phipps, MD, MPH, says, “There is not enough evidence to make a determination on screening pelvic exam in asymptomatic women for conditions other than cervical cancer screening, gonorrhea, and chlamydia. Women with gynecologic symptoms or concerns should discuss them with their clinicians.” Phipps is department chair, Chace-Joukowsky professor of obstetrics and gynecology, and assistant dean for teaching and research on women’s health at the Warren Alpert Medical School of Brown University in Providence, RI.
Thomas Gellhaus, MD, president of the American College of Obstetricians and Gynecologists (ACOG), said the national professional society is reviewing the Task Force’s draft recommendation statement and the evidence upon which it is based. ACOG recommends annual pelvic examinations for patients 21 years of age or older, noted Gelhaus in a statement. However, the College recognizes that this recommendation is based on expert opinion and limitations of the internal pelvic examination for screening should be recognized, he stated. “Notably, there are many women who are likely to benefit from a pelvic exam,” said Gellhaus. “For example, women who report or exhibit symptoms suggestive of female genital tract problems, menstrual disorders, vaginal discharge, incontinence, infertility, or pelvic pain should receive a pelvic examination.”
The draft recommendation statement concludes that there is not enough evidence to determine the benefits or harms of performing screening pelvic exams in asymptomatic, nonpregnant adult women for four conditions: ovarian cancer, bacterial vaginosis, genital herpes, and trichomoniasis, noted Gellhaus.
Part of Wellness Exam?
Women should see their obstetrician/gynecologists at least once a year, ACOG emphasizes. In addition to the screenings, evaluations, and counseling that clinicians can provide, the annual well-woman visit is an opportunity for the patient and her provider to discuss whether a pelvic examination is appropriate for her. The society promotes shared communication and decision making between the patient and the provider regarding the practice.
While most women who come in for a well-woman visit are prepared to have a pelvic examination, patients are best served by a clinician who performs pelvic examinations not routinely, but for specific reasons, says Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine –Jacksonville.
Kaunitz offers the following observations from his practice:
- When seeing symptom-free adolescent patients, such as those presenting to initiate short-acting hormonal or implantable contraception, Kaunitz orders urine screening for chlamydia, but he does not perform a pelvic examination. These young women are so relieved to learn they will remain fully dressed and avoid the dreaded “pelvic,” he notes. For symptom-free patients in their 20s, Kaunitz perform pelvic examinations only when indicated for cervical cancer screening.
- When seeing new adult patients, Kaunitz says he prefers to proceed with a pelvic examination. Why? His concern is that failing to perform an exam in this setting may miss relevant conditions his history may have failed to detect, such as pelvic prolapse, genital atrophy, lichen sclerosis or other vulvar conditions, and vaginitis.
“Experienced clinicians recognize that some women may not understand that symptoms caused by these conditions are not normal; therefore, they do not report symptoms when providing a history,” Kaunitz states. “Embarrassment or lack of knowledge regarding their genital tract may also prevent some women from reporting symptoms.”
Kaunitz often sees adult patients returning for visits, including medication refill visits. When a focused history reveals no gynecologic symptoms or changes, he indicates that he doesn’t recommend performing a pelvic exam.
- For menopausal patients returning for well-woman visits, Kaunitz periodically performs external genital inspections without speculum or bimanual examinations. His rationale is that women benefit from recognizing that changes of genital atrophy are present, even if they do not choose to treat this condition.
“Pelvic examinations are unpleasant and intrusive,” says Kaunitz. “While some of my adult patients prefer to have a complete pelvic exam with each well-woman visit, I note that more and more of my patients are delighted to avoid this time-honored, but not always indicated, ritual.”
The pelvic exam, as it is currently conducted, is not an efficient screening test, and with the increase in obesity, it is becoming increasingly insensitive, says Anita Nelson, MD, professor emeritus in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. While there are more sensitive tests, such as ultrasound imaging, they are not cost-effective, she observes. Thus, for now, clinicians will do no examination, she observes.
“This may increase clinician liability; we will have to find ways to elicit complete histories to ensure that the woman is truly asymptomatic, and we will have to find ways to explain to women why we are not providing them this test without making them think we do not care about their health,” states Nelson. “And we need to make certain that our colleagues do not think that this diminishes the importance of women’s reproductive health.”
