You don’t need that annual pelvic exam. So why is your doctor giving you one?
In June, the American College of Physicians (ACP) reported what many doctors have known for years: There is little justification for the widespread practice of the annual pelvic exam. In its clinical guidelines, the physicians group recommended against performing the exams for non-pregnant women who don’t have pelvic pain or other symptoms that suggest a gynecologic problem. These guidelines do not apply to Pap smears for cervical cancer screening, for which there is strong evidence for their continued use. They apply to the pelvic exam, where the clinician first uses a speculum to perform an internal exam, and then with his or her hands, feels for pelvic organs.
The guidelines are based on an extensive review of nearly 70 years’ worth of studies looking at the benefits and harms of the annual pelvic exam. After decades of research, the studies don’t show any benefits to performing this annual exam. When surveyed, many doctors said that they do the pelvic exam to screen for ovarian cancer, yet the review found that the pelvic exam could not effectively detect ovarian cancer, nor reduce deaths from it. Nor did the exams reduce deaths from non-ovarian and non-cervical cancers.
The review did find, however, that more than a third of women who received pelvic exams reported pain or discomfort and a similar percentage of women reported fear, embarrassment or anxiety. Not surprisingly, women who had experienced sexual abuse were more likely to experience these harms. This finding is particularly troubling because doctors don’t always know about their patients’ histories of sexual abuse.
Additionally, when low-risk patients are examined, the vast majority of abnormal exams end up being false alarms. The findings turn out to be false, however, only after additional workup is done. This workup may include ultrasounds or CT scans, specialty referrals, and even biopsies or surgeries. These procedures and evaluations may expose patients to radiation, put them at risk for complications such as bleeding or infection, and add costs. One study showed that pelvic exams resulted in a 1.5 percent increase in unnecessary surgeries. Even normal results from a pelvic exam may be problematic, because a pelvic exam’s ability to detect ovarian cancer is so poor that a normal result may be a false reassurance.
Despite these findings, an alarming number of physicians continue to conduct annual pelvic exams. That’s partly because of a position taken by the organization that establishes guidelines for gynecologists, the doctors who conduct the majority of pelvic exams in the United States. After the publication of the recent ACP guidelines, the American College of Obstetricians and Gynecologists (ACOG) reported that it “firmly believes in the clinical value” of the annual pelvic exam, even though it acknowledges that its recommendations were “not evidence based.”
So why does the gynecologist group still promote the annual pelvic exam? First, it argues that annual pelvic exams can help gynecologists recognize issues such as urinary incontinence and sexual dysfunction. In reality, however, clinicians learn about these conditions primarily through a medical interview; rarely would they first discover them through an exam.
The group’s leadership has also stated that annual pelvic exams are warranted because patients expect them. Yet doctors routinely advise against unnecessary treatments or procedures even when doing so bucks patient expectations. I don’t prescribe antibiotics, for example, if I suspect a nonbacterial cause of an illness, even when a patient asks for them.
Finally, ACOG argues that the annual pelvic exam is an important part of the “well-woman visit” that helps to establish “open communication” between patient and doctor by allowing doctors to “explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions.” Developing open communication and educating patients are important goals, but not at the expense of unnecessary and invasive examinations. If the clinician’s and patient’s time is freed up from the unnecessary examinations, the clinician can spend more time and attention counselling the patient on nutrition, exercise and sexual health.
Misdirected and unnecessary activity saps clinicians and patients of their precious time and attention. It keeps clinicians from being fully present with patients and doing work of greater value. Unneeded examinations and additional testing takes a financial toll on patients and on an already overextended healthcare economy.
The widespread practice of the annual pelvic exam is diverting our clinical attention and resources — and may be doing more harm than good. All clinical guidelines should reflect the evidence and honor medicine’s commitment to the safety and health of patients.
PHOTOS: First year Northwestern University medical students perform a pelvic exam on rubber dummies during their human anatomy class in Chicago, Illinois, March 15, 2007. REUTERS/Joshua Lott