Pelvic Exam Debate Continues to Rage

Early this summer, the American College of Physicians (ACP) said that for many women, there is no need for a routine, annual pelvic examination. Like many such sweeping conclusions about a longstanding clinical practice, it caused confusion among patients and disagreement in some medical corners.

An article called “You don’t need that annual pelvic exam. So why is your doctor giving you one?” by Dr. Deepthiman Gowda on, reviewed the situation earlier this month.

The revised guidelines for pelvic examinations were published in the Annals of Internal Medicine and were based on reviews of nearly 70 years’ worth of studies about the benefits and harms of the standard gynecological practice. The meta-analysis (review of a whole body of studies over an extended period) showed no benefits to performing this exam as part of routine care for most women.

Doctors who were surveyed said that they perform it to screen for ovarian cancer, but the analysis found that the pelvic exam did not effectively detect ovarian cancer, nor reduce deaths from it. Also, the exams did not reduce deaths from nonovarian and noncervical cancers.

The ACP – a national organization of internists whose mission is to apply scientific knowledge and clinical expertise to the diagnosis, treatment and care of people both healthy and seriously ill – recommended against performing pelvic exams for women who aren’t pregnant and who don’t have pelvic pain or other symptoms that suggest a gynecologic problem.

So the group was very clear that women still require the standard scrutiny of Pap smears to screen for cervical cancer, as experts remain united in the belief that there is strong evidence for their continued use for this purpose. The revised guidelines are specifically for the aspect of the pelvic exam in which the doctor uses a speculum to perform an internal exam, then uses his or her hands to palpate the pelvic organs.

When low-risk patients are examined, according to the report, the vast majority of abnormal exams turn out to be false alarms. That invariably invites additional tests that can be uncomfortable, expensive and present complications of their own – ultrasound, CT scans, specialty referrals, biopsy or even surgery. One study, Gowda reported, showed that pelvic exams resulted in a 1.5% increase in unnecessary surgeries.

But even normal results from a pelvic exam might not be an accurate picture of a woman’s health status. These exams aren’t very good at detecting ovarian cancer, so a normal result could invite false reassurance.

None of this is news, but thousands of physicians continue to conduct annual pelvic exams anyway. That’s largely because the American Congress of Obstetricians and Gynecologists (ACOG) says they should. After the ACP review was published, ACOG said that it “firmly believes in the clinical value” of the annual pelvic exam, despite the remarkable admission that its recommendations were “not evidence based.”

“So why does the gynecologist group still promote the annual pelvic exam?” Gowda, an internist, asked. One reason is because ACOG says that annual pelvic exams can help gynecologists recognize problems including urinary incontinence and sexual dysfunction. “In reality,” he said, “… clinicians learn about these conditions primarily through a medical interview; rarely would they first discover them through an exam.”

ACOG also said that annual pelvic exams are warranted because patients expect them. As readers of this blog know, overtreatment is a huge problem in U.S. health care, because it wastes resources and money, and because it can cause additional harms, like complications and needless worry from unnecessary tests. Part of a doctor’s obligation to his or her patient is to know this, and advise the patient about appropriate care, not to cave in to ill-informed pressure. As Gowda noted, “… doctors routinely advise against unnecessary treatments or procedures even when doing so bucks patient expectations. I don’t prescribe antibiotics, for example, if I suspect a nonbacterial cause of an illness, even when a patient asks for them.”

ACOG believes that the annual pelvic exam is an important part of the “well-woman visit”; that it helps to establish “open communication” between patient and doctor because it’s an opportunity for the professional to explain anatomy, reassure a patient of her of normalcy and answer her questions. But any good clinician does that every day; you don’t need a certain procedure to enable it; a procedure that is unnecessarily invasive and expensive. “If the clinician’s and patient’s time is freed up from the unnecessary examinations,” wrote Gowda, “the clinician can spend more time and attention counseling the patient on nutrition, exercise and sexual health.”

Last month, a commentary in the New York Times addressed the situation of the two medical societies at opposite ends of the pelvic exam debate. Its conclusion? “Women will need to make their own judgments about procedures that many of them, and their doctors, may have used for years as a matter of standard practice.”

Maybe. But how do women know if their practitioner is offering objective, evidence-based advice, or only adhering to what he or she has always done? Absent a history of gynecological/sexual problems or pregnancy, we think doctors should take the lead in curbing overtreatment that benefits no one except those who collect the checks.

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