EXECUTIVE SUMMARY

Researchers at the University of California, San Francisco, have looked at the effect of providing healthy women with information about pelvic examinations, including a professional society’s strong recommendation against them. In a just-released study, they report that a brief counseling session that includes the recommendation against such examinations led to a decrease in the patients’ desire for them.

  • The American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic examinations in asymptomatic women.
  • While the American College of Obstetricians and Gynecologists does call for annual pelvic exams for women 21 years of age and older, it also states that the decision to perform such exams should be individualized, sharing input from the woman and the clinician.

Researchers at the University of California, San Francisco, (UCSF) have looked at the effect of providing healthy women with information about pelvic examinations, including a professional society’s strong recommendation against them. In a just-released study, they report that a brief counseling session that includes the recommendation against such examinations led to a decrease in the patients’ desire for them.1

The American College of Physicians and the American Academy of Family Physicians recommend against performing screening pelvic examinations in asymptomatic women.2,3 While the American College of Obstetricians and Gynecologists (ACOG) does call for annual pelvic exams for women 21 years of age and older, it also states that the decision to perform such exams should be individualized, sharing input from the woman and the clinician.4

To perform the current study, 190 women visiting health clinics at UCSF and Zuckerberg San Francisco General Hospital and Trauma Center were shown illustrations of the pelvic examination. The women then were assigned randomly to review a summary of one of the two recommendations, then answer a series of questions assessing their attitudes and beliefs about the examination. One summary included information from the American College of Physicians about the potential for false-positive testing and unnecessary surgery. The other summary included information from the ACOG. It disclosed the lack of evidence of benefit, but did not mention the possibility of harm.

The analysis indicates that desire for the examination dropped from 82% for women who reviewed the favorable recommendation to 39% for those reviewing the discouraging recommendation. More than 90% of women in the study said that potential benefits and harm should be discussed prior to the examination.

“For every two or three women shown the recommendation, one of them would opt out of the examination,” says George Sawaya, MD, a UCSF professor of obstetrics, gynecology and reproductive sciences, and a leader at the UCSF Center for Healthcare Value. “This is an enormous effect for a five-minute education intervention.”

Given the potential public health impact of the team’s findings, researchers believe there is a “pressing need” for improving patient counseling concerning pelvic exams.

“These findings point to the need for educational materials to ensure women’s informed preferences and values are reflected in decisions about pelvic examinations,” said senior author Miriam Kuppermann, PhD, MPH, a UCSF professor in the departments of obstetrics, gynecology and reproductive sciences, and epidemiology and biostatistics.

What’s Your Practice?

Current evidence is insufficient to determine the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, adult, non-pregnant women for the early detection and treatment of many gynecologic conditions, according to March 2017 guidance from the U.S. Preventive Services Task Force. The new publication applies to women age 18 years and older who do not have 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.5 (Contraceptive Technology Update reported on the subject; see the May 2017 article, “More Research Needed on Benefits, Harms of Screening Pelvic Exams,” at: http://bit.ly/2sRHXmP.)

When it comes to birth control, the U.S. Selected Practice Recommendations for Contraceptive Use states that pelvic examinations are not necessary before initiation of combined hormonal contraceptives because they “do not facilitate detection of conditions for which hormonal contraceptives would be unsafe.”6

Many providers may continue to perform pelvic exams to detect ovarian cancer in asymptomatic women; however, it may not be effective. Results from a 2011 randomized trial of 78,216 women ages 55 to 74 demonstrated that screening with CA-125 and pelvic sonograms (a practice more accurate than bimanual examinations) is ineffective in preventing ovarian cancer mortality.7

The trend toward not performing pelvic exams at the time of annual exams or provision of contraception is well underway, observes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta.

“At the 2017 Contraceptive Technology conference in San Francisco, I met a clinician who said 90% of the LARC methods she was inserting for university students were implants,” says Hatcher. “When asked why, she said so many of these young women now get to the senior year of college without having a single pelvic exam, and they would rather have their contraceptive in their arm rather than in their uterus.”

REFERENCES

  1. Sawaya GF, Smith-McCune KK, Gregorich SE, et al. Effect of professional society recommendations on women’s desire for a routine pelvic examination. Am J Obstet Gynecol 2017; doi: http://dx.doi.org/10.1016/j.ajog.2017.05.003.
  2. 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.
  3. American Academy of Family Physicians. Clinical practice guideline: Screening pelvic examination in adult women. Available at: http://bit.ly/2nt3b4a. Accessed July 21, 2017.
  4. American College of Obstetricians and Gynecologists. Practice Advisory: Screening Pelvic Examination. Available at: http://bit.ly/2mK2Qu4. Accessed July 21, 2017.
  5. US 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.
  6. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-66.
  7. Buys SS, Partridge E, Black A, et al; PLCO Project Team. Effect of screening on ovarian cancer mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011;305:2295-2303.