By Rebecca H. Allen, MD, MPH

Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck and a Liletta trainer for Actavis, and she has served on advisory boards for Bayer and Pharmanest.

The recent draft guidance from the United States Preventive Services Task Force (USPSTF) on the utility of periodic screening with the pelvic examination has inspired renewed debate on this topic.1 The last time this subject made national news was in 2014 when the American College of Physicians (ACP) recommended against screening pelvic examinations in asymptomatic adult women.2 At the time, I was not surprised that a group of internal medicine physicians recommended against routine pelvic examinations, as they typically are not very comfortable performing them. Nor do they have the anecdotal experiences that obstetrician-gynecologists share: the asymptomatic patients in whom we have diagnosed vulvar cancer, congenital anomalies, or pelvic masses with the pelvic exam. Surprisingly, the ACP document was endorsed by our colleagues in the American Academy of Family Physicians.3 Based on national data, the USPSTF reported that the majority of preventive care visits to obstetrician-gynecologists (76%) included a pelvic examination compared to family medicine physicians (25%) and internal medicine physicians (14%).1 The pelvic exam consists of three elements: 1) inspection of the external genitalia; 2) speculum examination of the vagina and cervix; and 3) bimanual palpation of the uterus, cervix, and adnexa. A rectovaginal exam also can be performed when indicated. Current American College of Obstetrician and Gynecologist (ACOG) guidelines endorse performing a pelvic examination annually in all patients 21 years of age or older, with the caveat that the decision to perform an internal exam should be a shared decision between the provider and the patient.4

USPSTF Conclusions About Periodic Screening with the Pelvic Examination

The recent publication from the USPSTF pertained to asymptomatic, non-pregnant women 18 years of age or older who are not at risk for specific gynecologic conditions.1 The recommendations did not include using the pelvic exam for testing for cervical cancer or sexually transmitted infections. Overall, the USPSTF did not find any studies that assessed the effectiveness of pelvic examination in reducing all-cause mortality, reducing cancer- and disease-specific morbidity and mortality, or improving quality of life. The USPSTF noted that the pelvic exam, as an intervention, is difficult to study, as it can detect multiple gynecologic disorders including ovarian, uterine, vaginal, and cervical cancer, bacterial vaginosis, candidiasis, genital warts, genital herpes, trichomoniasis, pelvic inflammatory disease, cervical polyps, endometriosis, ovarian cysts, uterine fibroids, and pelvic organ prolapse. Nevertheless, the USPSTF reviewed the literature on the ability of the pelvic exam to detect these various conditions and found only four studies on ovarian cancer (n = 26,432), two studies on bacterial vaginosis (n = 930), one study on genital herpes (n = 770), and one study on trichomoniasis (n = 150). The largest study on palpation of the ovaries to detect ovarian cancer, the Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial, determined that the sensitivity was only 2.8% (95% confidence interval, 0.6%-8.6%).5 This is not new information for obstetrician-gynecologists, as we have long known that the bimanual exam is a poor test for ovarian cancer. Any abnormality on pelvic exam would be followed up with an ultrasound examination. Whether this leads to an increased use of healthcare resources than is otherwise needed is unknown. In the PLCO trial, the surgery rate after an abnormal ovarian palpation examination within one year of the abnormal screen was 11.2% (at the longest follow-up) with a complication rate (any complication: surgical, pulmonary, cardiovascular, infection, other) of 1.0%.1 Potential false-positive or false-negative exams for infectious diseases are less concerning given that the vast majority of providers perform further tests for these conditions and do not rely on the pelvic exam alone. The USPSTF concluded that “the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, non-pregnant adult women.”

ACOG’s Response to the USPSTF Guidance

ACOG agreed with the USPSTF that more research is needed in this area and acknowledged that the ACOG recommendations for annual pelvic exams were based on expert opinion.6 ACOG stated that women should have annual well-woman check-ups for preventive services and counseling whether or not a pelvic exam is included. ACOG also emphasized that a thorough review of systems should be performed, as some women may not recognize that certain signs or symptoms are abnormal. ACOG previously had stated that routine pelvic exams are not needed for the initiation of contraceptives (except intrauterine devices) and sexually transmitted infection testing (which can be done with urine samples or vaginal swab).4 In addition, ACOG guidance previously had specified that it would be reasonable to stop performing pelvic examinations in asymptomatic women when a women’s age or other health issues reach a point at which she would no longer choose to treat any conditions found on exam, presumably based on her life expectancy. ACOG’s current recommendations for well woman care according to age groups can be found at: http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations.

Potential Psychological Harms of the Pelvic Exam

The USPSTF was unable to find any studies that quantified the potential psychological harms of performing routine pelvic exams.1 This was a big part of the ACP recommendation against routine pelvic exams. The ACP guidelines stated that, based on its review, a median of 35% of women across eight studies reported pain with pelvic exams and a median of 34% of women across seven studies reported fear, embarrassment, or anxiety with pelvic exams.2 The concern is that these women would be less likely to return to a physician for further care. Of note, these studies were of low quality and were not included in the USPSTF review because of their lack of generalizability and applicability to the U.S. primary care setting. The USPSTF did acknowledge that certain subgroups of women, such as those with a history of sexual violence or abuse, chronic pelvic pain, or obesity, report more negative experiences from pelvic exams. Again, this is not new information for obstetrician-gynecologists, who I believe take great care to be compassionate and understanding when women present with these issues.

Take-home Message

In a nationally representative survey of obstetrician-gynecologists, almost all surveyed physicians indicated that they would perform a bimanual examination during a routine visit with an asymptomatic patient.7 Reasons cited as very important for performing the exam included adherence to standard medical practices (45%), patient reassurance (49%), detection of ovarian cancer (47%), and identification of benign uterine (59%) and ovarian conditions (54%). I agree with ACOG that the decision to perform an internal pelvic exam can be shared between the provider and patient. I believe that it has value, but I cannot say that it needs to be performed on an annual basis. I think the decision will come down to clinical judgment on the part of the provider based on the woman’s individual circumstances. Nevertheless, I feel strongly that a routine external examination of the genitalia is important, given that many women do not perform self-examinations of that area and certainly other medical providers will not be looking “down there.” I am also certain that obstetrician-gynecologists are the most trained in pelvic examinations and, therefore, are the best situated to make the exam as comfortable as possible for the patient.

REFERENCES

  1. Draft Recommendation Statement: Gynecological Conditions: Periodic Screening With the Pelvic Examination. U.S. Preventive Services Task Force. June 2016. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement157/gynecological-conditions-screening-with-the-pelvic-examination. Accessed Oct. 31, 2016.
  2. Qaseem A, Humphrey LL, 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.
  3. American Academy of Family Physicians. Clinical Practice Guideline: Screening Pelvic Examination in Adult Women. Available at: http://www.aafp.org/patient-care/clinical-recommendations/all/screeningpelvicexam.html. Accessed Oct. 31, 2016.
  4. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee opinion no. 534: Well-woman visit. Obstet Gynecol 2012;120:421-424.
  5. Buys SS, Partridge E, Greene MH, et al. Ovarian cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial: Findings from the initial screen of randomized trial. Am J Obstet Gynecol 2005;193:1630-1639.
  6. American College of Obstetricians and Gynecologists. Practice Advisory: Screening Pelvic Examination. Available at: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Screening-Pelvic-Examination. Accessed Oct. 31, 2016.
  7. Henderson JT, Harper CC, Gutin S, et al. Routine bimanual pelvic examinations: Practices and beliefs of US obstetrician-gynecologists. Am J Obstet Gynecol 2013;208:109.e1-7.