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Doctor group suggests skipping routine pelvic exams

By Andrew M. Seaman

NEW YORK (Reuters Health) - Most women should not get routine pelvic exams, according to a new guideline from a group of U.S. internal medicine doctors.

The recommendation by the American College of Physicians (ACP) is separate from guidelines regarding Pap smears. It also doesn’t apply to women who have symptoms such as abnormal bleeding or pain or who are pregnant.

Researchers found a lack of evidence to suggest routine pelvic exams save lives or improve health in the long run. But they can cause pain, discomfort and fear.

“In the absence of demonstrated benefit and in the presence of demonstrated harm, the equation just goes on the side of not doing something,” Dr. Linda Humphrey said.

Humphrey is a co-author of the new guideline and a member of ACP’s Clinical Practice Guidelines Committee. She is also associate chief of medicine at the Portland VA Medical Center in Oregon.

Pelvic exams are typically done to look for any abnormalities in the vagina and surrounding organs. Doctors feel a woman’s stomach to check the internal organs, examine exposed parts of the reproductive system and use a device called a speculum to check internal areas of the vagina.

About 63 million pelvic exams were done in the U.S. in 2010, according to an editorial accompanying the new guideline, which is published in ACP’s Annals of Internal Medicine.

Humphrey told Reuters Health the group was prompted to look at pelvic exams because they are closely linked to cervical cancer screenings. Recently other medical organizations and task forces have suggested screening certain women for cervical cancer every few years instead of annually, but they did not address pelvic exams, she said.

“The thinking behind it was we need to understand the data on this part of the exam now that the cervical cancer guidelines have changed,” Humphrey said.

A review of past studies compiled for the ACP and published in the same journal did not find evidence to support routine pelvic exams in asymptomatic women.

What’s more, there is some evidence to suggest that the exams may cause pain, discomfort, fear, anxiety or embarrassment in about a third of women, according to the review, which was led by Dr. Hanna Bloomfield from the Minneapolis Veterans Affairs Health Care System.

“There was some concern that the fear of the exam would cause women to not come in and not seek care when they need it,” Humphrey said, adding that pelvic exams may also lead to unnecessary care if a doctor erroneously suspects a problem.

In a statement emailed to Reuters Health, the American College of Obstetricians and Gynecologists (ACOG) said it stands by its guidelines, which complement those from the ACP.

For low-risk women without symptoms, ACOG recommends “the decision about whether to perform a pelvic examination be a shared decision between health care provider and patient, based on her own individual needs, requests and preferences.”

But ACOG also said it believes in the clinical value of pelvic exams, because doctors can detect issues such as incontinence and sexual dysfunction.

“Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy and answer her specific questions, thus establishing open communication between patient and physician,” the statement added.

In the linked editorial, Drs. George Sawaya and Vanessa Jacoby from the University of California, San Francisco write that ACP’s announcement should prompt those who recommend routine pelvic exams to demonstrate the screening does more good than harm.

“Remember there are two sides to any screening claim,” Sawaya told Reuters Health. “They have to make a claim that the net benefit is worth it.”

He added that it’s reasonable for women to discuss pelvic exams with their doctor at this point. The talk should touch on what they hope to achieve by having the exam done and whether there are any downsides.

“I think it’s totally reasonable for women to opt out of the exam,” Sawaya said. “If they do opt out, they should not be denied any other services like contraception or anything like that.”

He also said it’s important for women to know the ACP recommendation only applies to women without symptoms. “Certainly if patients have symptoms they should talk with their doctor and if it’s warranted an examination should be performed,” he added.

SOURCE: http://bit.ly/SQRXAa Annals of Internal Medicine, online June 30, 2014.

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