Call to end routine pelvic exams on women
The largest medical specialty group in the U.S. is recommending doctors stop routinely performing pelvic examinations in women.
The American College of Physicians (ACP) says that, for average-risk women who are not pregnant and who have no signs or symptoms of possible pelvic disease, the internal exams expose women to “unnecessary and avoidable harms” with no proven benefit. But the organization representing Canada’s gynecologists say the once-unquestioned procedure should remain an “integral” and fundamental part of women’s health care.
What is a pelvic exam?
The exam consists of visual inspection of the external genitalia, speculum examination of the vagina and cervix and “bimanual” examination of the uterus, ovaries and bladder. For the bimanual exam, a doctor inserts two fingers inside the vagina and places a hand on top of the abdomen, feeling for the position, shape and size of the uterus and ovaries. “Screening pelvic examination,” means speculum and bimanual exams in women with no pelvic symptoms.
The procedure has been taught to doctors for decades, said Dr. Molly Cooke, past president of the ACP (whose members are internal medicine doctors) and a member of the group’s clinical practice guidelines committee.
Why is it done?
Pelvic exams are performed to detect cancer (other than cervical cancer), noncancerous masses, pelvic inflammatory disease or other benign gynecological conditions before symptoms develop. The new guideline does not apply to Pap smears for cervical cancer. Pap smears are of “incontrovertibly proven benefit,” Cooke said. But pelvic exams are frequently performed in women who aren’t due for a Pap smear. In the U.S., 62.8 million pelvic exams were performed in 2010 alone.
What did the authors do?
The new guideline is based on a systematic review of medical literature published from 1946 through to January 2014.
What did the authors find?
According to the new guideline, screening pelvic exams rarely detect important disease and don’t reduce mortality. The exams have a low level of accuracy for detecting ovarian cancer — the main condition that it was hoped could be detected earlier by routine bimanual exams. “It’s reasonable to be concerned about ovarian cancer, because it’s a nasty cancer,” Cooke said. But several large studies have shown “it just doesn’t reliably detect ovarian cancer.”
The exams, meanwhile, can lead to false positive findings, unnecessary followup tests and procedures, as well as fear, anxiety, embarrassment, pain and discomfort. The new guideline appears in this week’s edition of Annals of Internal Medicine, ACP’s flagship journal.
What does the Society of Obstetricians and Gynaecologists of Canada recommend women and doctors do?
“We still consider a bimanual examination an integral part of a pelvic examination,” said Dr. Jennifer Blake, CEO of the Ottawabased organization. There are women for whom routine pelvic exams would be “clearly inappropriate,” she said, including women who have experienced sexual violence or trauma.