By: Candace McGregor, MD
Many women are celebrating what sounds, at first, to be the demise of the annual pelvic exam. In a recent review of scientific evidence, the American College of Physicians recommends against performing yearly pelvic exams for healthy low-risk women. Does this mean that they can toss out those speculums and never use those stirrups again? Not so fast! The experts of the American College of Obstetricians and Gynecologists agree in part with the new recommendations, but there are still some complexities to discuss. There are reasons for a woman to consider the value of the pelvic exam.
The pelvic exam consists of three parts: first, the provider inspects the external anatomy to look for redness, rashes, ulcers, and growths. Second, the speculum is inserted to examine the cervix and deeper portion of the vagina. This is often when the pap smear sample is taken. The pap smear is a screening test specifically for cervical cancer. Current medical guidelines suggest that people who haven’t had abnormal pap smears have a pap smear every 3rd year (21- 29 years of age) or every 5th year (30-65 years of age). A pap smear does not always have to be performed with a pelvic exam. The final part of the pelvic exam occurs when the provider presses on the uterus and ovaries through the vagina. The proper location, size, and texture of the organs are confirmed with this third part of the exam.
So, if a woman isn’t due for a pap smear, is the pelvic exam “worth it”? That is a very difficult question to answer. It is easy to design a research study to test whether a certain medication helps to reduce cholesterol – give a group the medication, watch lab results, and compare their numbers to a group that didn’t get the medication. However, the benefit of any physical examination or even counseling a practitioner provides is much more difficult to ascertain. Peter Lipson, a physician member of the American College of Physicians, and a contributing author to Forbes magazine provides examples of questions research just can’t answer: “How many marriages were saved by impromptu counseling? How many people felt less depressed by being able to talk to their doctor? How many people treated their blood pressure better by getting praise from the doctor?” These questions are much harder to address with research studies. If the other parts of the physical exam like listening to the heart and lungs were similarly researched, they would likely find the same lack of evidence to support its benefit.
When one critically analyzes the research behind the new recommendations from the American College of Physicians, its persuasiveness is quite limited. The research was based solely on the ability of the routine pelvic exam to detect ovarian cancer and to detect an infection called bacterial vaginosis. When the scientific data was unable to detect a difference in outcomes for these two conditions, the authors of the study then made a broad generalization that the pelvic exam was of no value. Women’s health practitioners, in rebuttal, point to a list of over 50 conditions that abnormalities on the pelvic exam can detect. Why would the value of the exam be determined based on just 2 of these?
There are times in performing a routine pelvic exam that diseases or problems can be identified that either the patient wasn’t aware of or that they were too uncomfortable to bring up. For example, the pelvic exam may find that a postmenopausal woman has vaginal atrophy – a thinning and dryness of the vaginal skin that can lead to irritation and painful intimacy. Once this is identified during the pelvic exam, the provider can initiate a conversation about the condition and possible treatment options. Or, the provider may find a bulge in the vagina caused by a condition called pelvic organ prolapse. This condition can be associated with leakage of urine. Once this is found on exam, the provider can inquire as to whether leaking is a problem for the patient and again discuss possible treatment options. As for younger patients, signs of infection can be detected that could lead to testing and treatment before the symptoms occur. If based on the newly reported recommendations, the pelvic exam was not performed in the above women, these conditions may have gone undiagnosed.
In healthy women without symptoms, the value of the routine yearly pelvic exam may be limited, and as the American College of Obstetricians and Gynecologists suggests, the decision whether to perform the complete pelvic exam when a pap smear isn’t due “should be a shared decision after a discussion between the patient and her health care provider”. However, clear reasons exist to go ahead and have the exam for certain women. These include women having problems such as menstrual period changes, vaginal discharge, and pelvic pain. Also, women with a family history of ovarian or breast cancers should strongly consider proceeding with a routine pelvic exam as they are at higher risk for developing pelvic tumors. Unfortunately, ovarian cancer is labeled “the silent killer” of women. Symptoms usually occur after the disease has become quite advanced, and the symptoms are often vague leading women to ignore them. Women with ovarian cancer may experience heaviness, bloating, change in appetite, or change in how their clothes fit. These symptoms may not be worrisome enough to a patient to talk to their provider about, but a pelvic exam may detect a lump worth getting tested.
So what is a woman to do the next time she is due for her yearly well-woman checkup? Have an open and honest conversation with her provider. Share concerns and then listen to the provider’s explanation of whether they think the exam would be of benefit. Whether a pelvic exam is performed or not, an annual visit provides an excellent opportunity for a practitioner to assess a woman’s overall health and to offer counsel about maintaining a healthy lifestyle and minimizing health risks.