New Debate Over the Effectiveness of Routine Pelvic Exams in Healthy Adult Women

Health Letter, December 2014

By Sarah Sorscher, J.D., M.P.H.

Guidelines published July 1 by a well-known professional association representing internal medicine physician in the U.S. have sparked new debate over the wisdom of conducting annual pelvic exams, a ritual many women have come to expect as part of their yearly checkup.

The guidelines of the American College of Physicians (ACP) advise against routine pelvic examination, in which a physician uses both hands to palpate (feel) a woman’s uterus and other organs, checking for signs of cancer, infections and other disease.[1]

In drafting its review, the ACP examined medical literature dating back more than six decades and found that annual pelvic exams do not benefit healthy, nonpregnant women who show no symptoms of and have no special risk factors for disease.

“[A pelvic exam] rarely detects important disease,” said Dr. Linda Humphrey, a co-author of the guidelines and a member of the ACP’s Clinical Guidelines Committee.

Humphrey added that the exam also causes discomfort for many women and often lead to false-positive results. In one group of studies considered by the ACP committee, patients did not actually have ovarian cancer in more than 95 percent of cases in which a physician found signs of possible cancer during a pelvic exam.[2] Such mistaken results can lead to unfounded anxiety and more unnecessary medical procedures, including ultrasounds, X-ray scans and even surgery to remove the suspected cancer.

The ACP took care to point out that the advice does not apply to Pap smear screenings, which are often done in combination with a pelvic exam. It also stressed that women who have symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems or sexual dysfunction may still need a complete pelvic exam with palpation of the uterus and other pelvic organs to help identify possible cancer and other diseases.

Opposing views

The American College of Obstetricians and Gynecologists (ACOG) distributed a press release opposing the ACP’s new guidelines and arguing that the decision whether to conduct the exam should be up to individual doctors and patients. “While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients,” the organization stated in defense of its position.[3]

ACOG’s opposition may be driven in part by the financial interests of its members, who specialize in women’s reproductive health. Like specialists in other fields of medicine, gynecologists tend to be compensated for each service performed in their specialty — such as testing that is ordered when a doctor finds problems during a pelvic exam — so ACOG members would have more to lose if fewer patients receive a pelvic exam and are referred to gynecologists for further evaluation.

By contrast, the ACP is made up of many different types of doctors who do not necessarily specialize in women’s reproductive health and therefore have less of a financial interest in pelvic exams. The new guidelines against routine pelvic exams are the latest in a series of controversial guidelines published by the ACP, including one in 2013 recommending against a common type of routine screening blood test for prostate cancer in average-risk men under age 50 or over age 69.[4] Not unexpectedly, the American Urological Association, a society of specialists who provide treatment for prostate cancer, rejected this approach, stating that “men should be informed of the risks and benefits” before undergoing the procedure.[5]

What should you do?

According to the best evidence, if you are a healthy adult woman who is not pregnant and not experiencing vaginal discharge, abnormal bleeding, pain, difficulties with urinating, sexual dysfunction or related problems, you should not receive an annual pelvic exam. Talk to your doctor about the new recommendations against screening, and ask if you can avoid this unnecessary procedure.

Even if you do not receive a pelvic screening, you should still go in for regular doctor’s appointments. Visiting your doctor provides an excellent opportunity to talk about effective care and discuss potential health risks. You may also require other types of routine screening that are effective at reducing health risks. How often you need to visit your doctor will depend on your age and other risk factors. Talk to your doctor about which screening tests are appropriate for you to learn how often you should come in for a visit.

If you would like more information to guide you when talking to your doctor about pelvic examinations, you can download the full ACP guidelines for free at the organization’s website (http://www.acponline.org/clinical_information/guidelines/guidelines/).


References

[1] Qaseem A, Humphrey L, Harris R, et al. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161:67-72.

[2] Ibid.

[3] American College of Obstetricians and Gynecologists (ACOG), ACOG Practice Advisory on Annual Pelvic Examination Recommendations. June 30, 2014. http://www.acog.org/About-ACOG/News-Room/Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations. Accessed October 17, 2014.

[4] Qaseem A, Barry M, Denberg T, et al. Screening for prostate cancer: a guidance statement from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2013;158:761-769.

[5] Greene K, Albertsen P, Babaian R, et al. Prostate specific antigen best practice statement: 2009 Update. 2013;189:S2-S11.