ACOG Issues Recommendations on Routine Pelvic Exam, Cervical Cytology Screening

Fran Lowry

April 22, 2009

April 22, 2009 — The American College of Obstetricians and Gynecologists (ACOG) has issued a committee opinion on routine pelvic examination and cervical cytology screening that will be published in the May issue of Obstetrics and Gynecology.

The recommendations of ACOG Committee Opinion Number 431 come with the caveat that the document "reflects emerging clinical and scientific advances as of the date issued and is subject to change," writes ACOG's Committee on Gynecologic Practice. "The information should not be construed as dictating an exclusive course of treatment or procedure to be followed."

ACOG decided to issue the guidelines because the advent of the human papillomavirus vaccine has given rise to some confusion about when, and in whom, to perform periodic health assessments in women.

The recommendations on when to start screening, how often to continue screening, and when to stop routine pelvic examination and cervical cytology are based on age.

For women younger than 21 years who have never been sexually active, no routine pelvic examination, cervical cytology, or testing for sexually transmitted disease (STD) is needed. If the women have ever been sexually active, however, ACOG recommends cervical cytology be performed 3 years after the onset of sexual activity, and annually thereafter. Routine pelvic examination should be performed only when indicated by the patient's medical history.

For women aged 21 to 29 years, ACOG recommends an annual pelvic examination and cervical cytology. Sexually active women aged 25 years or younger should be screened for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Urine-based screening without a speculum examination is sufficient for such screening, according to ACOG.

ACOG also says that all adolescents and women aged 19 to 64 years who are sexually active should be screened for HIV.

For women aged 30 to 64 years, the recommendation is for annual pelvic examination plus cervical cytology. However, screening can be decreased to every 2 to 3 years after 3 normal test results if the patient has no history of cervical intraepithelial neoplasia (CIN) 2 or CIN3, is not immunosuppressed, is not HIV-positive, and was not exposed to diethylstilbestrol (DES) in utero.

For women older than 65 years, ACOG recommends an annual pelvic examination. However, cervical cytology may be discontinued if the woman has had 3 or more normal test results in a row, no abnormal test results in 10 years, no history of cervical cancer, no DES exposure in utero, is HIV-negative and immunocompetent, and does not have other risk factors for STDs. The need to begin screening again should be evaluated at each annual examination.

The pelvic examination is not a routine part of the annual health examination in girls aged 13 to 18 years, unless it is medically indicated. It should be performed when it is likely to yield information about amenorrhea, abnormal bleeding, vaginitis, pelvic pain, an STD, a pelvic mass, or other conditions.

It is also reasonable to stop speculum and bimanual pelvic examinations in asymptomatic women who have had a total hysterectomy and bilateral oophorectomy for benign indications, although annual examination of the external genitalia should continue.

It would also be reasonable to stop pelvic examination when a woman's age or other health issues reach a point where the woman would not choose to treat conditions detected during the routine examination. Such a decision should be discussed between the patient and her physician, ACOG recommends.

Obstet Gynecol. 2009;113:1190–1193.

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