The new pelvic exam guidelines from the American College of Physicians may be a relief for women who would prefer to forgo the annual ritual, but they could also lead to variation in well-woman care, depending on which type of specialist provides that care.
The guidelines advise physicians to skip annual pelvic examinations in otherwise healthy, asymptomatic women who are not pregnant (Ann. Intern. Med. 2014;161:67-72).
Dr. Jill Rabin
The evidence-based clinical practice guidelines recommend that cervical cancer screening be limited to the visual inspection of the cervix and cervical swabs for cancer and human papillomavirus. They recommend against performing a speculum examination of the vagina and cervix, and a bimanual examination of the adnexa, uterus, ovaries, and bladder. The recommendation does not apply to using the Pap smear to screen for cervical cancer.
The diagnostic accuracy of the pelvic exam in detecting gynecologic cancer or infections is low, the ACP said, and carries the risk of false positives that can lead to unnecessary testing and procedures. The embarrassment and discomfort of the exam may also keep some women from seeking care, the ACP stated in the guidelines.
But that advice conflicts with an August 2012 policy statement from the American College of Obstetricians and Gynecologists, which recommends that pelvic exams be performed in asymptomatic adults as part of an annual well-woman visit. However, citing a lack of evidence, the opinion leaves the decision about when and how often to perform the exams in the hands of physicians and patients (Obstet. Gynecol. 2012;120:421-4).
Following the release of the ACP guidelines, ACOG issued a statement renewing its support for the pelvic exam, but saying that the ACOG policy was a "complement" to the new ACP recommendations. ACOG said that the use of the exam is "supported by the clinical experiences of gynecologists treating their patients."
It’s a position shared by Dr. Jill Rabin, professor of obstetrics and gynecology at Hofstra North Shore–LIJ School of Medicine and head of urogynecology at Long Island Jewish Medical Center in New Hyde Park, N.Y. She currently performs a full pelvic exam during the well-woman visit and plans to continue doing so.
"I want every woman to get a full exam every year and whoever does it, they should do a good job," Dr. Rabin said.
She praised the ACP guideline, saying that she agreed that there was a lack of evidence and that the exams can create anxiety and embarrassment. But pelvic exams are also essential in uncovering conditions such as pelvic floor weakness, fibroids, and vulvovaginal atrophy, Dr. Rabin said. And the exam provides a unique opportunity for women to bring up concerns that they might not raise during a history taking, she said, such as symptoms of incontinence.
As for the lack of evidence, Dr. Rabin said researchers should begin those studies even if they take decades to provide complete answers.
"There’s a lot that we do in life where we don’t have the studies," she said. "But lack of the evidence doesn’t mean that there’s lack of value."
And Dr. Rabin isn’t alone in doing a full pelvic exam. A recent survey of ob.gyns. found that nearly all perform bimanual pelvic examinations in asymptomatic women for a variety of reasons including patient reassurance, detection of ovarian cancer, or identification of benign uterine and ovarian conditions (Am. J. Obstet. Gynecol. 2013;208:109.e1-7).
Dr. Molly Cooke
Dr. Molly Cooke, the ACP’s immediate past president and a member of the group’s Clinical Practice Guidelines Committee, said that for years she performed pelvic exams in asymptomatic patients mainly out of "habit," rather than evidence. But with the ACP’s new guidelines, she plans to change her approach.
Going forward, Dr. Cooke said she will discuss the utility of the pelvic exam with patients and explain that the evidence indicates that the bimanual exam does not produce meaningful information and could lead them astray. She said she expects that most patients will agree to forgo the pelvic exam when presented with the evidence.
As for ob.gyns. who may continue to perform pelvic exams routinely in asymptomatic patients, Dr. Cooke said that they are essentially making a "faith-based" assertion about the usefulness of the exam.
Dr. Cooke said the ACP recommendations are meant to apply to all clinicians who provide well-woman care. "We don’t see any reason why the guideline isn’t as useful and applicable to a nurse practitioner, a gynecologist, a family physician, and an internist," she said.
The new ACP guidelines are being well received by some internists and family physicians who are feeling the pressure to cram more and more preventive care into a short visit.