By Alexandra Morell, MD
Clinical Instructor, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
A retrospective chart review of 1,121 patients undergoing annual gynecology exams showed that 1.2% (95% confidence interval [CI], 0.5 to 1.9) of asymptomatic patients had physical exam findings on pelvic exam compared to 32.4% (95% CI, 27.0 to 37.8) of symptomatic patients.
Norby N, Sabu P, Locklear T, et al. Incidence of abnormal findings during pelvic examinations in women aged 21-35 years. Obstet Gynecol 2024;143:6-8.
An estimated 34.7 million pelvic examinations were performed in the United States in 2018.1 Traditionally, a pelvic exam was performed as part of an annual well-woman visit in asymptomatic women to detect pelvic masses, malignant conditions, pelvic infections, and other gynecologic pathology.2 Over the last several years, the American College of Obstetricians and Gynecologists (ACOG) and other organizations, such as the United States Preventive Services Task Forces (USPSTF), the American Academy of Family Physicians (AAFP), the Society of Gynecologic Oncology (SGO), and the American College of Physicians (ACP), have provided updated recommendations regarding routine pelvic examinations in asymptomatic women.3-7 Currently, ACOG recommends a shared decision-making approach involving a conversation regarding the risks and benefits of a pelvic exam and proceeding with an exam based on this discussion.3
This was a retrospective chart review of annual gynecology visits at a single academic center over two months assessing the incidence of abnormal findings detected on pelvic exam in symptomatic vs. asymptomatic patients. Inclusion criteria included nonpregnant patients between ages 21-35 years with a low risk of sexually transmitted infections (STIs). A total of 1,121 annual visits met inclusion criteria. Patient charts were reviewed for demographic variables, including age, body mass index, smoking status, obstetric history, race, ethnicity, and insurance information. All charts were reviewed by two investigators, with a third investigator conducting a review if any discrepancy was noted. The primary outcome was abnormal physical exam findings during a pelvic exam. For statistical analyses, Fisher exact tests were used for categorical variables, while medium two-sample tests were used for numerical variables. Two-proportion z-tests were used to analyze the primary outcome.
Of the 1,121 patients, 834 (74%) were asymptomatic at their annual visits, while 287 (26%) reported symptoms to their provider. Of all the patients included, a majority were white (80%), nonsmokers (68%), and currently insured (93%). There were significant differences between symptomatic and asymptomatic patients regarding race, smoking status, and insurance status, with a higher proportion of non-Caucasian patients (P ≤ 0.001), current or former smokers (P ≤ 0.001), and uninsured patients (P = 0.002) reporting symptoms.
Only 10 asymptomatic patients (1.2%; 95% confidence interval [CI], 0.5 to 1.9) had incidentally detected abnormal findings on pelvic exam and 93 symptomatic patients (32.4%; 95% CI, 27.0 to 37.8) had abnormal findings (P ≤ 0.001). Of the symptomatic patients, the most common complaints were vaginal discharge, pelvic pain, vaginal bleeding, concern for STI, and dyspareunia. In symptomatic patients, pelvic pain (n = 14) and abnormal vaginal bleeding (n = 3) were confirmed on pelvic exam 100% of the time, vaginal discharge (n = 42) was confirmed 91.3% of the time, and external lesions (n = 22) were confirmed 88% of the time. For asymptomatic patients, one patient was diagnosed with an adnexal mass, four patients were diagnosed with bacterial vaginosis or a yeast infection, and five patients had external or internal lesions.
COMMENTARY
Historically, a pelvic examination has been a routine part of a well-woman annual gynecologic exam. Although pelvic exams were performed to assess for asymptomatic gynecologic pathology, a main indication for yearly pelvic exams related to cervical cancer screening. In 1975, ACOG published formal guidelines regarding cervical cancer screening. The initial guidelines suggested Pap smear screening should be performed starting at 18 years of age or at the onset of sexual activity, if sooner. Repeat screening was recommended six to 12 months after the first screening test, followed by annual screening in patients with two negative tests.8
Since 1975, cervical cancer screening guidelines have changed drastically. In 2012, screening recommendations for cervical cancer changed to start at the age of 21 years regardless of sexual activity and screening at three- or five-year intervals, depending on the patient age and type of screening test performed.9 Although annual pelvic exams were useful when yearly cervical cancer screening was recommended, it is necessary to reevaluate the benefit of a pelvic exam outside of this screening.
Currently, ACOG recommends a shared decision-making approach to performing pelvic exams and counseling patients regarding the risks and benefits before performing a pelvic exam.10 ACOG suggests the potential benefits of a pelvic exam include early detection of cancer and benign dermatologic changes prior to becoming symptomatic. At minimum, an external genital exam may detect skin lesions since this is an area of the body where the patient and/or primary care physician may not routinely evaluate. Potential harms include fear, pain, anxiety, and embarrassment.3
SGO echoes the shared decision-making model recommended by ACOG. SGO emphasizes the importance of offering an exam and argues that a conversation between a patient and provider about a pelvic exam allows a woman to practice autonomy and decide for herself.6 In contrast, the ACP and the AAFP have guidelines recommending against routine pelvic examinations. Both organizations report that the harms outweigh the benefits.5,7
The results of this study provide an argument against performing pelvic exams in asymptomatic, nonpregnant patients, since the detection of incidental findings in asymptomatic women was extremely low. Only 10 out of 834 asymptomatic patients had incidental findings on exam. Five patients were incidentally found to have internal or external lesions, and it is unknown if these lesions were benign or cancerous. Interestingly, four of the asymptomatic patients were diagnosed with yeast or bacterial vaginosis infections. It is unclear how these diagnoses were made and what prompted testing for these infections if the patients did not have symptoms.
Overall, in this patient sample, there was minimal benefit to a pelvic exam in asymptomatic patients. Currently, there are not consistent guidelines about routine pelvic exams in low-risk asymptomatic populations. When it comes to the shared decision-making approach that is recommended by ACOG, this article provides a framework for discussing potential benefits with patients and, specifically, addressing the low likelihood that a pelvic exam will identify pathology when symptoms are not present.
REFERENCES
- Centers for Disease Control and Prevention. National Center for Health Statistics. National Ambulatory Medical Care Survey: 2018 National Summary Tables. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2018-namcs-web-tables-508.pdf
- Stormo AR, Hawkins NA, Purvis Cooper C, Saraiya M. The pelvic examination as a screening tool: Practices of US physicians. Arch Intern Med 2011;171:2053-2054.
- [No authors listed]. ACOG Committee Opinion No. 754: The utility of and indications for routine pelvic examination. Obstet Gynecol 2018;132:e174-e180.
- 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.
- American Academy of Family Physicians. Screening pelvic exam. Clinical Preventive Service Recommendation. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/screening-pelvic-exam.html#:~:text=Given%20the%20low%20likelihood%20of,recommends%20against%20screening%20pelvic%20exams.
- Society of Gynecologic Oncology. Position statement on pelvic examinations. Published Oct. 1, 2016. https://www.sgo.org/newsroom/position-statements-2/pelvic-examinations
- 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.
- Waxman AG. Guidelines for cervical cancer screening: History and scientific rationale. Clin Obstet Gynecol 2005;48:77-97.
- Marcus JZ, Cason P, Downs LS Jr, et al. The ASCCP Cervical Cancer Screening Task Force endorsement and opinion on the American Cancer Society Updated Cervical Cancer Screening Guidelines. J Low Genit Tract Dis 2021;25:187-191.
- [No authors listed]. Vaginitis in nonpregnant patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol 2020;135:e1-e17.
