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Whither the Routine Pelvic Exam?

June 30, 2014

Whither the Routine Pelvic Exam?

  1. Andrew Kaunitz, MD

The American College of Physicians recommends against performing routine pelvic examinations as part of well-women visits.

  1. Andrew Kaunitz, MD

Sponsoring Organization: American College of Physicians (ACP)

Target Population: Clinicians who conduct well-woman visits

Background and Objectives

Women and clinicians alike have typically perceived vaginal speculum and bimanual examinations as an integral part of the well-woman visit. Now, the ACP has issued evidence-based guidance challenging this time-honored practice. The ACP's review indicates that routine pelvic examination is not useful in screening for malignancies other than cervical cancer, can lead to unnecessary additional evaluation and surgery, often causes discomfort and embarrassment, and may deter some women from receiving gynecologic care.

Key Recommendations

  • Routine pelvic examination is not recommended in asymptomatic nonpregnant adult women.

  • This recommendation does not apply to routine cervical cancer screening. Such screening should include vaginal speculum examination with visual inspection of the cervix and collection of cervical specimens, but not bimanual examination.

  • Screening for chlamydia and gonorrhea can be accomplished with nucleic acid amplification testing of urine specimens or self-collected vaginal swabs.

Comment — Women's Health

  1. Andrew Kaunitz, MD

In 2012, the American College of Obstetricians and Gynecologists recommended that speculum and bimanual examinations be part of annual well-women visits in women 21 and older (NEJM JW Womens Health Aug 23 2012). As an editorialist notes, obstetrician-gynecologists universally continue to perform routine pelvic examinations — and ending this practice represents a “formidable challenge.” During well-women visits, I have encountered patients with bacterial vaginosis, mucopurulent cervicitis, severe vulvovaginal atrophy, advanced vulvar lichen sclerosus, and cervical polyps who did not report any symptoms in histories taken before their examinations. These observations typify asymptomatic patients who would benefit most from routine pelvic examination. Most of my adult patients continue to prefer such examinations; nonetheless, I have been selectively performing them less commonly beginning years ago for my adolescent patients and in 2012 (coincident with updated cervical cancer screening guidelines [NEJM JW Womens Health Apr 12 2012]) for my adult patients. In general, I anticipate that this ACP guidance will result in fewer routine pelvic examinations.

Comment — General Internal Medicine

  1. Allan S. Brett, MD

In my view, this guideline is valid. The ACP found no studies in which researchers rigorously assessed whether routine screening pelvic examinations confer benefit, and they found indirect evidence that routine exams might trigger potentially harmful downstream interventions. Anecdotal observations are likely specialty-specific: Most of Dr. Kaunitz's patients prefer these examinations, whereas most of my patients seem happy to discontinue them. In addition, gynecologists are more likely to find asymptomatic abnormalities (such as those listed above by Dr. Kaunitz) than are generalists, but we still need evidence that the benefits of discovering and treating those abnormalities are sufficient to warrant routine screening exams. However, discontinuing the routine pelvic examination does not exempt us from routinely taking a good gynecologic history, which can reveal symptoms that warrant pelvic examination. Moreover, we should acknowledge that many parts of the routine nongynecologic physical examination also are not backed by evidence showing that they improve the health of asymptomatic patients.

  • Disclosures for Andrew Kaunitz, MD at time of publication Consultant / Advisory board Actavis plc; Bayer AG; Merck; Teva Pharmaceutical Industries Limited; UpToDate Royalties UpToDate Grant / Research support Trimel Pharmaceuticals Corp; TherapeuticsMD; NIH Editorial boards Contraception; Menopause; Contraceptive Technology Update; OBG Management; Medscape OB/GYN & Women’s Health Leadership positions in professional societies North American Menopause Society (Secretary)

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

Citation(s):

Reader Comments (20)

Pepi Granat, MD Physician, Family Medicine/General Practice, My office: Pepi Granat, MD and South Miami Hospital

Perhaps internists, who -- by nature of their specialty -- do not have occasion to do many pelvic exams, and are tempted to go by the literature when deciding on this issue, thinking that "evidence" comes only from collected and published works. But practicing OB-GYNs and Family Physicians, who do pelvics regularly are in the position of having multiple personal experiences (call it anecdote but it's significant, & is "evidence" of a different sort) of picking up and dealing with nearly all the conditions, often in asymptomatic patients, listed by our OB-GYNs in their astute comments.here on this list. Let's look at it this way: would the OB-GYNs come out with a recommendation not to put a stethoscope on the chest of women/men, or palpate their thyroids, since the yield is so low? Patient visits should be not ONLY about "screening" but also "case-finding". I'd like to have a nickel for all the pathology I've picked up, by doing pelvics AND listening to the chest. PG, MD

Pepi Granat, MD Physician, Family Medicine/General Practice, Pepi Granat, MD & South Miami Hospital

It is understandable, coming from internists, who -- despite being considered generalists -- are really what we in Family Medicine call "partialists". Unfortunately, internists may have been taught to do pelvic exams in medical school, but have usually (almost never) considered Gynecology their province, and therefore have not developed the confidence, expertise and ongoing management of nearly all the conditions listed by our OB-GYNs in their astute comments. We in Family Medicine DO consider it our province and (especially we female physicians) have much practice at it. Let's look at it this way: would the OB-GYNs come out with a recommendation not to put a stethoscope on the chest of women/men, or palpate their thyroids, since the yield is so low? Since when are our visits ONLY about "screening" versus "case-finding" ? I'd like to have a nickel for all the pathology I've picked up, by doing pelvics AND listening to the chest. PG, MD

Rene Shelly, DO Physician, Family Medicine/General Practice, Bluffton, OH

I think the current recommendation of pap screening every 3 years in low risk women provides a good time period for "routine" pelvic exams as well. As a female of "mature years" I still insist on a pelvic exam as part of health maintenance every three years based on my experience with patients. Some of my most serious pelvic diagnoses, some with fatal consequences, have happened in women who refused examination. In every case, I have strongly felt that physical exam would have led me to find the problem far earlier than what it was.
The other problem is that when women don't feel compelled to come in for pap/pelvic exams, they don't come in at all, so I don't get the chance to screen for other health problems and habits.

JOHN IVES Physician, Obstetrics/Gynecology, Retired

I would recommend continuing to do speculum examinations, for all the reasons listed in the "Comment" box above.
If there were specific symptoms to suggest uterine or adnexal pathology I would order a pelvic ultrasound rather than do a bimanual examination. If not I would not do a bimanual.

Sherrie Palm Other, Health Law/Ethics/Public Policy, Association for Pelvic Organ Prolapse Support

I find the ACP determination unsettling. Millions of women have pelvic organ prolapse and there is a significant lack of awareness/understanding of this common, cryptic women's health concern on both patient and practitioner sides of the fence. Practitioners are under-educated in POP and women are seldom aware the condition exists so the end result is discovery upon diagnosis frequently in an advanced stage. A significant misconception is women are asymptomatic when the reality is both patients and practitioners simply don't know the symptoms women are experiencing are classic POP symptoms. Accurate stat collection, need for practitioner curriculum evolution, and general awareness are all aspects that need to be addressed-without routine pelvic exams, the other layers will have a more difficult time cementing. I'm hopeful all fields of practice that perform pelvic exams will recognize the significant energy currently in motion which has potential to generate the next big shift in women's health directives.

Sherrie Palm Founder/Executive Director
Association for Pelvic Organ Prolapse Support

Deborah Lehmann MD FACOG Physician, Obstetrics/Gynecology, Fort Worth TX

The concept of screening and prevention is surely good; but, we have been undisciplined about the application of screening which can be harmful. Increasing public arguments about breast cancer screening are an indication that we are becoming more critical of results and risks of various screening protocols that had been well intentioned and widely accepted at the outset. We have over diagnosed and over treated cervical dysplasia for at least 3 decades and are backing away from this painfully and slowly, I think that we have also been over diagnosing and over treating breast cancer. Unfortunately, the tort factor makes it more difficult to do what is in the best interest of the patient and we defend ourselves by excessive testing. Our bottom line also is tied up in this argument; I notice ACOG is in favor of routine screening pelvic exams and the radiologists are in favor of screening mammograms.
Unfortunately, it is common for the patient to make an appointment for a "well woman" exam when she is having a problem that she expects you to discover ( and fix) after the exam. The government and insurance industry further the problem by making "Well Woman" exams "free".

ALBERT MARCUS Other, Obstetrics/Gynecology, retired

unfortiunately pelvic exam means pap test to most women. There is no argument that pap or HPV testing is not needed for every woman yearly and guidelines are valid ;. however, tumors of pelvic organs and other diseases can be discovered by routine yearly exams. We are doing women a disservice if we equate pap smears with pelvic exams

barbara merovich, M.D. Physician, Internal Medicine, jamestown , PA

in the past year, 3 patients who called for a "uti" or a "yeast infection", and deserved a pelvic exam due to ongoing symptoms for those, were found to have bladder cancer, endometrial cancer , and vulvar cancer respectively.
These are women who are older than 65 y/o on whom I wasn't planning on doing further gyne exams routinely. WIth this, I learn't that even though a pap will not be performed, at least checking the genital area can save lives in older women.

richard Thornton ACOG Physician, Obstetrics/Gynecology

What no citations from the Am J OB and Gyn.?
Who is doing the most pelvic exams?

And when routine pelvic exams have been dispatched, what
winds will blow then?

BEN REITER Physician, Family Medicine/General Practice, Office

Even though doing bimanual exams statistically are not indicated, will this protect a physician from liability in the case of a later discovered pelvic mass?

TARIK ZAMZAMI Physician, Obstetrics/Gynecology, Saudi Arabia, KAUH

In obstetric practice routine vaginal examination is not indicated in asymptomatic patients. But in gynecological practice pelvic examination is helpful to assess pelvic organs, any tenderness or anomalies

Jonathan Reggler MB BChir Physician, Family Medicine/General Practice

Sadly, it will be some time before this excellent advice from ACP takes hold. Those who continue to support routine bimanual pelvic exams betray their deep lack of understanding of the principles of screening (which is what the proponents of the BPE are attempting to do), the problem of false positives and the subsequent harms done to female patients in the investigation of "abnormalities" that did not need to be found or suspected in the first place. This has nothing to do with saving money and everything to do with the principle "first do no harm".

JOHN BARCLAY Physician, Family Medicine/General Practice, Delta, BC Canada

Such a recommendation is part of a general trend to reduce many aspects of the complete physical examination leading to an excessive reliance on the lab and imaging with increasing costs to health care.

Krystol O'Rourke Physician, Family Medicine/General Practice

Per the ACS:
Is a rectal exam enough to screen for colorectal cancer?

"Although a DRE is often included as part of a routine physical exam, it is not recommended as a stand-alone test for colorectal cancer. This simple test, which is not usually painful, can detect masses in the anal canal or lower rectum. By itself, however, it is not a good test for detecting colorectal cancer because its reach is limited."
" However, simply checking stool obtained in this fashion for bleeding with an FOBT or FIT is not an acceptable method of screening for colorectal cancer. Research has shown that this type of stool exam will miss more than 90% of colon abnormalities, including most cancers."

Elizabeth Allemann, MD Physician, Family Medicine/General Practice, Columbia Missouri

Thank you for answering a question my patients and I share: Is the bimanual part of the exam evidence-based? Quite a relief to know that it is not and will now be a service I offer but no longer recommend. Women around the world are breathing just a bit easier.

GREGORY MOORE Physician, Obstetrics/Gynecology

I suspect most aspects of what an internist/family medicine physician do during routine physicals on "well" patients are low yield as well. I have certainly picked up pelvic masses (benign and malignant) on "well woman" pelvic exams.

Wiilliam M. Petty, MD, FACOG Physician, Obstetrics/Gynecology, Community Care Center

Becoming competent in pelvic examinations is a slow, often neglected area of learning. Learning discernment of pelvic structures
does require time and concentration. The bladder must be empty. A recto-vaginal exam needs done to reach high in the pelvis. Right hand to right pelvis and left hand to left pelvis should be routinely performed. It is valuable if done properly.
It is is otherwise misleading to patient and clinician.

James Powers MD, FACP Physician, Internal Medicine

Logic dictates that fewer, or no, bimanual pelvic exams will reduce, if not eliminate the routine practice of digital rectal exams and the accompaning stool guaiac testing as part of the routine health maintenance exam. It appears that in the name of reducing costs, the ACP is supporting reducing appropriate women's health care. I am embarrassed by the current ACP position statement.

kristina nadreau DVM Other, retired

I agree with the comments that this recommendation is a cost saving feature at the expense of womens health. I also question the wisdom of having a male as head of "women's Health".

Angel GUEVARA, M.D. Physician, Family Medicine/General Practice, Hospital Universitari de Girona Doctor Josep Trueta

Who tells you she is a well-woman?

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