ABSTRACT & COMMENTARY

Is the Routine Pelvic Exam Obsolete?

By Joseph E. Scherger, MD, MPH

Vice President, Primary Care, Eisenhower Medical Center; Clinical Professor, Keck School of Medicine, University of Southern California, Los Angeles

Dr. Scherger reports no financial relationships relevant to this field of study.

SYNOPSIS: The American College of Physicians recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women.

SOURCE: Qaseem A, 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.

Representing the American College of Physicians,
a Minneapolis-based, evidence-based synthesis program center performed a systematic review of the English language literature from 1946 through January 2014 regarding the evidence for or against performing routine pelvic examination in adult women. With the exception of screening for cervical cancer, there was no evidence of benefit in screening for ovarian cancer or any other pathology. Potential harms were cited, although minor, and hence this new clinical guideline. As would be expected, this guideline conflicts with the policies of the American College of Obstetricians and Gynecologists, who recommend a pelvic exam as part of an annual well-woman visit.¹

The following clinical recommendations are made as part of this guideline:

1. Clinicians do not need to perform a pelvic examination before prescribing oral contraceptives.
2. Screening for sexually transmitted disease can be performed with urine testing or vaginal swabs and does not require a pelvic examination.
3. All or part of a pelvic examination is often indicated in women with such symptoms as vaginal discharge, abnormal bleeding, pain, urinary problems, and sexual dysfunction.
4. When screening for cervical cancer, examination should be limited to visual inspection of the cervix and cervical swabs for cancer and HPV.

COMMENTARY

This guideline is a major change in medical practice. Gone is the need for adult women to have a gynecologist just for well-women exams. Internists and family physicians should still be proficient in pelvic examination for the assessment of related health problems and for screening for cervical cancer. Routine Pap smears are no longer recommended annually,² but every 3 years in women between the ages of 21 and 65.² I predict that monogamous women who are HPV negative will be able to discontinue Pap testing in the future since the vast majority of cervical cancer is caused by the sexually transmitted HPV virus.

Much time and money are wasted in routine health care of no clinical benefit. If the routine pelvic exam becomes obsolete, the shortage of primary care physicians, especially in women’s health, will need to be recalculated.

REFERENCES

1. Committee on Gynecologic Practice. American College of Obstetricians and Gynecologists. Committee Opinion 534. Well-Woman Visit. Obstet Gynecol 2012;120:421-424.
2. U.S. Preventive Services Task Force. Screening for Cervical Cancer. March 2012. http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm