More Research Needed on Benefits, Harms of Screening Pelvic Exams
EXECUTIVE SUMMARY
Current evidence is insufficient to determine the balance of benefits and harms of performing screening pelvic exams in asymptomatic, nonpregnant adult women for the early detection and treatment of many gynecologic conditions, according to recent guidance from the U.S. Preventive Services Task Force.
- The new publication applies to women age 18 years and older who do not present with any signs or symptoms of gynecologic conditions and who are not at increased risk for such conditions.
- The task force already recommends using screening tests for early detection of cervical cancer, chlamydia, and gonorrhea.
Current evidence is insufficient to determine the balance of benefits and harms of performing screening pelvic exams in asymptomatic, nonpregnant adult women for the early detection and treatment of many gynecologic conditions, according to recent guidance from the U.S. Preventive Services Task Force (USPSTF).1 The new publication applies to women age 18 years and older who do not present with any signs or symptoms of gynecologic conditions and who are not at increased risk for such conditions. The USPSTF already recommends using screening tests for early detection of cervical cancer, chlamydia, and gonorrhea, but these may not require pelvic examinations.
“The task force is calling for more research to better understand the benefits and harms associated with performing screening pelvic exams to detect gynecologic conditions in women without any gynecologic signs, symptoms, or risk factors,” said USPSTF member Maureen Phipps, MD, MPH, department chair and Chace-Joukowsky professor of obstetrics and gynecology and assistant dean for teaching and research on women’s health at the Warren Alpert Medical School of Brown University in Providence, RI. “Until more research is available, clinicians should continue to use their clinical judgment, taking each patient’s individual values, preferences, and circumstances into consideration when deciding with patients whether or not a pelvic exam should be performed.”
The guidance is not a recommendation against performing pelvic exams, noted USPSTF Chair Kirsten Bibbins-Domingo, PhD, MD, in a statement accompanying the publication.
“At this time, there simply is not enough evidence to determine the benefits and harms of using pelvic exams to screen for conditions other than cervical cancer, chlamydia, and gonorrhea,” said Bibbins-Domingo, who also serves as professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco.
According to a Practice Advisory issued by the American College of Obstetricians and Gynecologists (ACOG), the “I” statement issued by the USPSTF should not be interpreted to mean that a screening pelvic exam should never be performed.2 The “I” represents “insufficient,” meaning there are not enough data to conclude whether the benefits of performing the exam outweigh any potential risks in asymptomatic women. The “I” ruling differs from a “D” ruling, which reflects no net benefit or that harms outweigh benefits.
Clinicians also must consider that the USPSTF recommendation does not apply to pregnant women, nor does it apply to women who present to their women’s health provider with signs or symptoms.
“It is critically important for obstetrician-gynecologists to elicit accurate and complete medical, surgical, and family histories and to conduct thorough reviews of systems as part of the well-woman visit,” the advisory states. “Some women may not recognize that certain signs or symptoms are truly abnormal; these signs and symptoms may be interpreted as “normal” for them, when, in fact, they should prompt evaluation, which may include a pelvic examination.”
Women should not forgo their well-woman care considering the USPSTF guidance, the advisory states. This preventive service visit also provides an opportunity for patients and providers to discuss whether a pelvic examination is appropriate for individual care.
The American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic exams in asymptomatic women.3,4 Although ACOG calls for annual pelvic exams for women 21 years of age and beyond, it also states that the decision to perform such exams should be individualized, sharing input from the woman and the clinician.
For Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the department of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville, performing a pelvic exam reflects such an individualized approach. For symptom-free women in their 20s or younger who are presenting for well-woman care or to initiate short-acting hormonal or implantable contraception, he orders urine screening for sexually transmitted infections when appropriate, but does not perform a pelvic exam unless requested by the patient or indicated for cervical cancer screening.
When seeing new, older adult patients, Kaunitz says he takes a different tack.
“Failing to perform an exam in this setting may miss relevant conditions my history may have failed to detect, such as pelvic prolapse, vulvar conditions, and vaginitis,” he notes. “Accordingly, my recommendation is to proceed with a pelvic exam, including vaginal speculum exam.”
When seeing return asymptomatic menopausal women, Kaunitz says he performs a visual external genital inspection. This type of exam often identifies atrophy; less often, it reveals lichen sclerosus or other vulvar pathology.
“Given the time constraints associated with well-woman visits, omitting exams when appropriate frees up time to focus on areas of importance to the patient, leading to increased patient satisfaction,” Kaunitz explains. “While some of my adult patients prefer to have a complete pelvic exam with each well-woman visit, I note that more and more of my patients prefer to skip this time-honored, but not always indicated, ritual.”
REFERENCES
- U.S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force Recommendation Statement. JAMA 2017;317:947-953.
- American College of Obstetricians and Gynecologists. Practice Advisory: Screening Pelvic Examination. Available at: http://bit.ly/2mK2Qu4. Accessed March 23, 2017.
- Qaseem A, Humphrey LL, Harris R, et al; Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161:67-72.
- American Academy of Family Physicians. Clinical practice guideline: Screening pelvic examination in adult women. Available at: http://bit.ly/2nt3b4a. Accessed March 23, 2017.
According to one expert: “At this time, there simply is not enough evidence to determine the benefits and harms of using pelvic exams to screen for conditions other than cervical cancer, chlamydia, and gonorrhea.”
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