Pelvic Exams: New Guidelines for Asymptomatic Women

Tinker Ready

July 24, 2012

July 24, 2012 — The American College of Obstetricians and Gynecologists (ACOG) has issued updated guidelines for annual "Well Woman" assessments with specific recommendations on when to perform pelvic exams in asymptomatic women and when to begin clinical breast exams.

The opinion supplements ACOG's physical exam recommendations, which were updated in 2011 and recommend exam requirements including schedules for vaccinations and screening such as Papanicolaou smears and bone mineral density tests.

The annual exam is "a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician–patient relationship," according to the opinion from the Committee on Gynecologic Practice, published as Committee Opinion 534 in the August issue of Obstetrics and Gynecology.

The opinion offers specifics on when to conduct routine pelvic exams on healthy, asymptomatic women. At the same time, the guidelines call for shared decision-making between asymptomatic patients and physicians over whether to perform an internal pelvic exam during an annual physical.

The document defines the pelvic exam as the external inspection of the genitalia urethra, vaginal, and anal region; a speculum exam of the vagina and cervix; and bimanual examination of the uterus, cervix, ovaries, and the Fallopian tubes.

ACOG recommends that pelvic exams be performed only when indicated by medical history for patients younger than 21 years. No evidence supports the routine exam for asymptomatic patient before age 21 years, "although it is recognized that pelvic pathology sometimes is identified by a pelvic examination on an asymptomatic patient." Speculum exams for cervical cancer screening should begin at age 21 years, irrespective of sexual activity of the patient.

ACOG recommends yearly full pelvic examinations for patients aged 21 years and older, but notes that the advice is based on "expert opinion, and limitations of the internal pelvic examination should be recognized." For example, the bimanual examination is useful for evaluating the uterus, but has a low sensitivity for detecting "adnexal masses," which include ovarian cysts and ectopic pregnancies.

Although annual pelvic exams for women older than 21 years seem "logical," the opinion notes that "[n]o evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient." In addition, no data exist on when and how often to perform the exam. Ultimately, the decision whether or not to perform a complete pelvic examination "should be a shared decision after a discussion between the patient and her health care provider."

The exam is always appropriate for patients with symptoms "suggestive of female genital tract problems." These include menstrual disorders, vaginal discharge, infertility, or pelvic pain. Perimenopausal patients with abnormal uterine bleeding, changes in bowel or bladder function, or vaginal discomfort should have a pelvic examination. The exam is also called for in older, menopausal women with abnormal bleeding, vaginal bulge, urinary or fecal incontinence, or vaginal dryness.

Physicians may stop performing pelvic examinations on woman who, because of age or other health issues, would choose not to treat conditions detected during the exam. The decision whether to have an exam can be left to the patient if she is asymptomatic and has undergone a total hysterectomy, had her ovaries and fallopian tubes removed for benign indications, has no history of cancer or some forms of precancerous neoplasia, is not HIV-positive or immunocompromised, and was not exposed to diethylstilbestrol in utero.

Physicians should consider family history and cancer risk, but the opinion states that an "exhaustive list of specific indications for a pelvic examination for all patients is beyond the scope of this document. Sound clinical judgment always must be the guiding factor in determining when a pelvic examination is indicated."

The document also recommends "breast self-awareness," which may include performing breast self-examination. The patient should immediately report changes in her breast to her physician. The opinion recommends that a clinical breast examination be performed annually in women aged 40 years and older based on evidence from ACOG, the American Cancer Society, and the National Comprehensive Cancer Network. In women aged 20 to 39 years, the same groups recommend a clinical breast examination every 1 to 3 years. The decision "to perform any type of pelvic or breast examination should always be made with the consent of the patient," according to the document.

Obstet Gynecol. 2012;120:421-424. Abstract

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