WOMEN'S HEALTH
July 16, 2014

The Dreaded Pelvic

They're sometimes painful, intrusive and now it appears they offer little benefit. The ACP comes out against routine pelvic exams. PAP smears not included.

The pelvic exam has long been an important part of the annual “well woman” checkup, but that may be changing. The American College Physicians (ACP) recently published a new practice guideline recommending against performing routine screening pelvic exams. The practice is unnecessary, the ACP says, unless a woman is pregnant or has symptoms suggesting there may be a problem.

The recommendation is based on a review of the research which found that routine pelvic exams did not reduce mortality and offered no demonstrated benefits. Pelvic exams rarely detected serious diseases such as ovarian cancer or bacterial vaginosis and were associated with discomfort, false positive and negative examinations, and extra cost.

A review of 52 studies finds little evidence to support routine pelvic exams for average-risk women with no gynecological symptoms.

The new guidelines are meant to advise physicians and women and to help them better understand the benefits, harms, and costs associated with pelvic exams. The hope is that doctors and patients will work together to decide on care that improves health, avoids harm, and eliminates unnecessary practices.

“Regardless of whether the ACP statement changes practice among obstetrician-gynecologists, it should provide a needed prompt for champions of this examination to clarify its goals and quantify its benefits and harms,” write the authors of an editorial published with the guidelines.

The review of 52 studies found little evidence to support routine pelvic exams for average-risk women with no gynecological symptoms. According to these studies, pelvic exams cause pain, discomfort, fear, anxiety, or embarrassment for about 33 percent of women.

As many as eight in 10 women experience emotional distress because of the test. In addition, false-positive results may lead to unnecessary, invasive, and potentially harmful diagnostic procedures.

Pap Smears Are Still Necessary
These new guidelines do not apply to Papanicolaou (Pap) smear screening, only the pelvic examination. Screening for cervical cancer should be limited to visual inspection of the cervix and cervical swabs for cancer, and, for some women, human papillomavirus (HPV), the ACP advises. It does not need to include the bimanual examination of the adnexa, uterus, ovaries, and bladder.

Pelvic exams remain appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.

Not everyone agrees with the ACP's recommendation. The American College of Obstetricians and Gynecologists (ACOG) still advocates for an annual pelvic exam, though the ACOG acknowledges the lack of scientific evidence in support of routine screening.

The need for a pelvic exam should be a shared decision between a health care provider and patient, based on her own individual needs and preferences, the ACP believes.

Pelvic examinations give gynecologists the opportunity to explain a patient’s anatomy and reassure her of normalcy. It also allows the physician to answer any specific questions she may have. Such a dialogue establishes a sound basis for communication between a patient and her physician, according to the College.

The revised ACP guidelines and accompanying editorial are published in Annals of Internal Medicine.

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