July 1, 2014
News Review From Harvard Medical School -- Doctors Say Routine Pelvic Exam Not Needed
Women don't need annual pelvic exams, a large group of primary-care doctors says. The American College of Physicians (ACP) says there is no good evidence that the exams provide a benefit. But the group does endorse regular screening tests for cervical cancer. These tests are recommended every 3 to 5 years. The new guideline applies to average women who are not pregnant and do not have symptoms of a problem. Pelvic exams are intended to look for infections, cancers and other problems in the reproductive organs. But research doesn't show that these exams are any good at finding these problems, an ACP committee found. Three studies on ovarian cancer found that pelvic exams did not help to detect it. One of the studies found that 1.5% of women ended up having surgery they did not need. Several studies looked at harms from regular pelvic exams. In 8 surveys, 11% to 60% of women called the exams painful or uncomfortable. In 7 studies, 10% to 80% of women said the exams caused fear, anxiety or embarrassment. The journal Annals of Internal Medicine published the study. HealthDay News wrote about it June 30.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
For men, the rectal exam is no longer a required part of the routine check-up. In the past, it was done primarily to feel the prostate gland. However, like blood PSA testing, the rectal exam is not an effective prostate cancer screening method.
Still, many doctors advise their male patients to have it done. It's a ritual that doctors learned in medical school. And it's hard to just "let it go."
Meanwhile, otherwise healthy, non-pregnant women continue to have routine pelvic exams. Many women have them each year. The pelvic exam includes a close look at the vagina and cervix using a speculum. This is followed by the gloved examination inside the vagina, during which the doctor feels:
- The cervix
- The uterus
- Both sides of the lower abdomen in the area where the ovaries and fallopian tubes are located
As they did with the rectal exam for men, researchers began questioning the value of the routine pelvic exam. Is it just a ritual because it seems the right thing to do? Or is there evidence to support its benefit?
According to the American College of Physicians (ACP), the evidence for benefit is not there. This group recommends against routine pelvic exams for non-pregnant women who feel fine. They based this advice on a systematic review of prior studies. They not only found no benefit, they found that the exam often causes discomfort and distress. Sometimes it also leads to surgery that is not needed.
Since I don't need to undergo the pelvic exam ritual, I called a couple of my female doctor colleagues to get their personal and professional reactions. Question: "Will you miss not having regular pelvic exams?" Response (paraphrased): Are you serious? No way will I miss them!
On further discussion with a fellow primary care doctor, we did acknowledge that some women will feel their check-up is not complete without a pelvic exam.
What Changes Can I Make Now?
You may not need routine pelvic exams. But you still need regular screening for cervical cancer. It can save your life.
Here are the screening guidelines for women at average risk of cervical cancer:
- Women ages 21 to 29 should have a Pap smear once every 3 years.
- Women ages 30 to 65 should have a Pap smear every 3 years or a Pap smear and a human papilloma virus (HPV) test every 5 years.
- Women ages 65 and older do not need routine screening if recent Pap smears have been normal.
These are guidelines. For personal reasons, you and your doctor may wish to choose HPV testing first or have more frequent Pap smears than recommended.
Pelvic exams will always remain an important part of the diagnostic evaluation for any symptoms that could be related to the vagina, cervix, uterus, fallopian tubes or ovaries.
However, if you are an otherwise healthy, non-pregnant woman, you may not need routine pelvic exams. You and your doctor can decide.
If your doctor does wish to perform the exam during a routine appointment, feel free to ask why you need it. You can also ask what the doctor is looking for. That's not a challenge. Based on current evidence, there should be a reason for doing a routine pelvic exam.
What Can I Expect Looking to the Future?
Doctors will likely be slow to let go of the ritual of the routine pelvic exam. I base this on my own approach to screening rectal exams in men. I still offer men a rectal exam as part of routine check-up. I do this because some men feel the check-up is not complete without a rectal exam. And I know they would not be comfortable asking me for it.
The American College of Obstetricians and Gynecologists (ACOG) still recommends a yearly pelvic exam for women. However, this group does say that evidence does not support or disprove its value. I suspect the current ACOG advice will not change in the near future.