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Doctors not ready to abandon annual pelvic exams

There still may be value in that annual pelvic exam.

When the U.S. Preventive Services Task Force released a statement saying there wasn't enough evidence to determine whether the standard pelvic exam was beneficial for women without symptoms and who are not pregnant, it might have felt like welcome advice for women who dread the annual precautionary look. But that doesn't mean the exams will — or should — be abandoned by everyone, says Dr. Samuel Smith, chairman of the department of obstetrics and gynecology at MedStar Franklin Square Medical Center and a board member of the American College of Obstetricians and Gynecologists' Council on Patient Safety in Women's Health Care.

What are doctors looking for during a pelvic exam?

The pelvic exam includes three elements: an external examination, a speculum examination of the vagina and cervix, and a bimanual examination of the uterus, cervix and adnexa (the latter two constitute the internal examination). When indicated, a rectovaginal examination also should be performed.

The American College of Obstetricians and Gynecologists recommends that pelvic examinations be performed on patients 21 and older unless a need is indicated by a younger patient's medical history. An "external-only" genital examination can provide the health care provider with the opportunity to evaluate the patient for normal external genital anatomy, issues of personal hygiene and abnormalities of the vulva, introitus and perineum that might require further investigation.

There are a variety conditions that are being screened for by the pelvic exam, including pain, discharge, rash and skin lesions (including melanoma and sexually transmitted diseases), swelling, abnormal anatomy and abnormal development. The pelvic exam is an important component of the evaluation of complaints, including itching, bleeding, menstrual abnormalities, sexual or physical trauma, pelvic pain, infertility, miscarriages, abnormalities of sexual development, urinary incontinence and pelvic organ prolapse.

Why have they traditionally been done annually?

An annual visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. A pelvic examination is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic or rectal problems.

There are some women who may benefit from a screening pelvic exam depending on their individual health condition and information shared during the appointment. Some women may not recognize that certain signs or symptoms are abnormal. These signs and symptoms may be interpreted as "normal" for them, when, in fact, they should prompt evaluation, which may include a pelvic examination. It is therefore important for obstetrician-gynecologists to elicit accurate and complete medical, surgical and family histories and to conduct thorough reviews of systems as part of the annual well-woman visit.

Pelvic examinations were once performed for cervical cytology or screening for gonorrhea or chlamydia before age 21. However, the availability of urine testing for gonorrhea and chlamydia and a better understanding of HPV and the progression of cervical cancer has reduced the need of routine pelvic examination before age 21.

What did the task force say about the exams' benefits?

On June 28, the U.S. Preventive Services Task Force released a draft recommendation statement, "Gynecological Conditions: Periodic Screening With the Pelvic Examination," as an "I" statement, which means that it concluded that there is not enough evidence to determine the benefits or harms of performing screening pelvic exams in adult women who have no symptoms and are not pregnant. ACOG responded by emphasizing that the task force draft "I" statement applies only to a pelvic exam for four specific gynecological conditions: ovarian cancer, bacterial vaginosis, genital herpes and trichomoniasis. Research is needed to examine the value of the exams beyond them.

What's the harm in continuing annual exams?

In my opinion, there is no well-documented harm in performing annual pelvic examinations. The "I" statement from the task forceshould not be interpreted to mean that a pelvic examination should never be performed. It means that there are not enough data to come to a conclusion about whether or not the benefits of performing the exam outweigh any potential risks in asymptomatic women. The task forceconcluded that evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined. This is not a recommendation that there is no net benefit.

How will practitioners decide who still needs them and when?

ACOG stresses that women should see their OB-GYNs at least once a year, and OB-GYN providers will generally follow the reasonable guidelines recommended by them. They promote open communication and decision making between the patient and the physician regarding pelvic examinations, recommending annual pelvic examinations for patients 21 or older. However, the college recognizes that this recommendation is based on expert opinion, and there are many women who would likely benefit from a pelvic exam. For example, women who report or exhibit symptoms of female genital tract problems, menstrual disorders, vaginal discharge, incontinence, infertility or pelvic pain should receive a pelvic examination.

meredith.cohn@baltsun.com

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