Clinicians continue unneeded pelvic exams

Results of a new national survey of obstetricians and gynecologists (OB/GYNs) show that many physicians mistakenly believe a routine annual bimanual pelvic examination is important in screening for ovarian cancer.1 The study reveals physicians continue to perform the exam in part because women have come to expect it.

When asked why they perform pelvic examinations for asymptomatic women, nearly half reported that ovarian cancer screening was a very important reason for the exam, despite longstanding evidence that the exam is ineffective for preventing ovarian cancer deaths, notes Jillian Henderson, PhD, MPH, research associate at the Kaiser Permanente Center for Health Research in Portland. In fact, its use for this purpose can lead to serious harms from treatment of false positive results, states Henderson, who served as lead author for the paper.

Most physicians also reported that pelvic exams were very important for detection of benign uterine and benign ovarian conditions, such as fibroids and cysts, in women without any symptoms, states Henderson. Other important reasons were to reassure patients of their health and accommodate patient expectations, as well as adherence to standard medical practice, states Henderson.

"Finally, nearly half of OB/GYNs indicated that the exam was very important or moderately important to conduct in order to ensure adequate financial compensation for a visit," says Henderson. "This highlights the need for better mechanisms to compensate OB/GYNs for their valuable contraceptive, sexual, and reproductive health counseling, regardless of whether or not a physical exam is conducted."

Why the persistence?

Results of a 2011 published survey of 1,250 U.S. internists, family practitioners/general practitioners (FP/GPs), and OB/GYNs found that half of all physicians reported conducting routine pelvic exams as part of a well-woman exam.2 When it came to ovarian cancer screening, routine pelvic exams were reported by 95.2% of OB/GYNs, 55.2% of FP/GPs, and 29.7% of internists; for screening for other gynecological cancers, the percentages were 96%, 68%, and 41.2%, respectively. More than 90% of OB/GYNs said they routinely performed such exams to screen for sexually transmitted infections (STIs), compared to 72.9% of FP/GPs and 39.9% of internists.

The current survey delves deeper into the practices of OB/GYNs, notes co-author George Sawaya, MD, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. The current research team asked specific reasons for the exam and used vignettes to better understand if the clinical situation affected the performance of, and the importance the clinicians placed on, the exam, he explains.

What do experts say?

The American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion in August 2012 to supplement its 2011 physical exam recommendations to better help clinicians understand when pelvic exams are needed.3,4

What constitutes a pelvic exam? According to ACOG, it includes three parts: an external inspection, an internal speculum exam, and a combination internal/external exam. Annual pelvic exams should begin at age 21, the organization notes. For younger women, however, an internal exam is not recommended unless a patient has signs of a menstrual disorder, vaginal discharge, pelvic pain, or other reproductive-related symptom.3

Screening for STIs, especially in certain age groups, is an important part of the annual exam, but STI testing now can be done using urine samples or vaginal swabs without an internal pelvic exam, ACOG notes. Pelvic exams also are not necessary before prescribing birth control pills.

When are pelvic exams appropriate? Check the following scenarios as listed by ACOG:

  • as part of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract problems;
  • when patients present with menstrual disorders, vaginal discharge, infertility, or pelvic pain;
  • when perimenopausal patients present with abnormal uterine bleeding, changes in bowel or bladder function, or symptoms of vaginal discomfort;
  • when patients in later reproductive years and menopause present with pelvic symptoms related to abnormal bleeding, vaginal bulge, urinary or fecal incontinence, or vaginal dryness.3

Bimanual examination also is indicated before procedures, such as an endometrial biopsy, inserting an intrauterine device, or fitting a diaphragm or pessary, ACOG guidance states.3

A patient's personal and family medical history and known risk factors for gynecologic malignancies can affect the decision regarding the indications for a pelvic examination, the guidance notes. Sound clinical judgment always must be the guiding factor in determining when a pelvic examination is indicated, the guidance states.

References

  1. Henderson JT, Harper CC, Gutin S, et al. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists. Am J Obstet Gynecol 2012. Doi:10.1016/j.ajog.2012.11.015.
  2. Stormo AR, Hawkins NA, Cooper CP, et al. The pelvic examination as a screening tool: practices of US physicians. Arch Intern Med 2011; 171(22):2,053-2,054.
  3. The American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. Committee opinion number 534: Well-woman visit. Obstet Gynecol 2012; 120:421.
  4. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 483: Primary and preventive care: periodic assessments. Obstet Gynecol 2011; 117(4):1,008-1,015.