Another argument in favor of the pelvic exam: I see at least one patient every day who is referred to me by her primary care doctor and who has not, over the course of her care for the current complaint, had to take off her clothes for a comprehensive examination. She typically is sent to me because of a finding on magnetic resonance imaging (MRI) or computed tomography (CT). Not uncommonly, women are convinced they have cancer based on these incidental findings. Yet those findings usually turn out to be a perfectly benign entity of little consequence, such as a benign fibroid tumor of the uterus. The power of the physical exam is that it can document things such as fibroids before they turn up on an MRI or CT scan. That is much less stressful for the patient than having a mysterious lesion identified on imaging, necessitating referral to a specialist to identify the problem.
No barriers to care
I don’t think women like the pelvic exam any more than they like mammograms or being physically vulnerable in any way. In my experience, however, patients tend to experience more trepidation about stepping onto the scale than about undergoing a pelvic exam.
Am I going to create a barrier to a patient’s care by insisting on weighing her or on performing a pelvic exam after she voices her desire to avoid these things?
Of course not.
Certainly, if a patient declines either of these options, I honor her wishes. However, I make it a point to have a conversation with her about their intrinsic value.
I try to teach my patients that they are the owners of their bodies, and that everything that occurs in the doctor-patient relationship is collaborative. In my practice, women always have the option to say “No.”
I do agree with Dr. Westhoff and colleagues that some women are turned off by the prospect of a pelvic exam. Adolescents, in particular, are often apprehensive about it. When I see a teenager for her first gynecologic visit, I usually focus on discussion. I try to get to know her and attempt to give her a sense of control over her own body. When it comes to the pelvic exam, I give her a choice—and I honor her decision.
Other patients who may be unwilling to undergo an annual pelvic exam include women who have a history of sexual abuse or molestation. Again, I respect their wishes, but I do talk to them about the value of the physical.
Unlike Dr. Westhoff and colleagues, however, I don’t believe that “no annual pelvic exam” should be our default position. And although there are other components of gynecologic care to see to besides the pelvic exam, I don’t think the exam should be dispensed with in the interest of saving time. In actuality, the pelvic exam is probably the least time-consuming aspect of gynecologic care for an asymptomatic patient.
In my view, the purpose of the annual visit is to identify risks and manage them—and some risks may be overlooked if I don’t have the opportunity to examine the patient. At the annual well woman visit, I have a conversation with the patient about the risks she faces over the next year, depending on her age and overall condition, and I devote quite a bit of time to this discussion. But I don’t do it at the expense of a careful pelvic exam.
Instead, I honor the ritual and the critical information it yields.
INSTANT POLL: A patient arrives for her annual well-woman examination. What do you do?
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