Value of Screening Pelvic Exam for Women Debated

Lara C. Pullen, PhD

July 02, 2014

The American College of Physicians (ACP) has issued new clinical guidelines recommending against screening pelvic examination in asymptomatic, nonpregnant, adult women. The college describes the recommendation as strong, with moderate-quality evidence.

Molly Cook, MD, a general practitioner who served on the ACP Clinical Guidelines Committee, spoke with Medscape Medical News about the new guidelines. She sees the guidelines from the perspective of her role as a general practitioner and the choices she must make during the limited time she has with patients: "That 20 minutes is really crowded, and I want to use my time in ways that are particularly going to benefit women."

Pelvic examinations are commonly used as a screen for pathology in asymptomatic, nonpregnant, adult women. ACP has reviewed the literature and determined that the screening pelvic examination does not benefit adult women. Although the recommendations advise against pelvic examinations, the recommendation for Papanicolaou smears remains.

Amir Qaseem, MD, PhD, from the American College of Physicians, Philadelphia, Pennsylvania, and colleagues developed the guidelines for the Clinical Guidelines Committee of the ACP. The guidelines were published online July 1 in the Annals of Internal Medicine.

The authors reviewed the evidence and found that the harms associated with screening pelvic examination outweigh the benefits. The guidelines also explain that screening for chlamydia and gonorrhoea, sometimes done by pelvic examination, can be reliably performed using nucleic acid amplification tests on self-collected vaginal swabs or urine. “[N]ucleic acid amplification tests on self-collected vaginal swabs or urine have been shown to be highly specific and sensitive, and this technique is supported by several organizations,” the authors write.

In their recommendation, they add, "With the available evidence, we conclude that screening pelvic examination exposes women to unnecessary and avoidable harms with no benefit (reduced mortality or morbidity rates). In addition, these examinations add unnecessary costs to the health care system ($2.6 billion in the United States). These costs may be amplified by expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results; increased medical visits; and costs of keeping or obtaining health insurance."

Robert Morgan, MD, codirector of the Gynecological Cancers Program at City of Hope in Duarte, California, is uncomfortable with the new guidelines, and expressed his discomfort in an interview with Medscape Medical News. He acknowledged up front that he is a medical oncologist and that his specialty colors his viewpoint and drives his desire to continue to screen for cancer. "I am really concerned that in 10 years, we are going to see people who have put off their routine [Papanicolaou] smears," he explains.

The American College of Obstetricians and Gynecologists (ACOG) also has reservations about the ACP clinical guidelines. In a press release, ACOG states that it stands by its current guidelines for well-women visits, which includes pelvic examinations. The college believes the choice to perform pelvic examinations is one that should be made on the basis of a woman's individual needs, requests, and preferences.

ACOG believes that an annual pelvic examination remains a useful tool, in particular for the recognition of incontinence and sexual dysfunction. The college also emphasizes the importance of other aspects of the well-woman visit, including clinical breast examination, immunizations, and contraceptive discussion.

"We continue to urge women to visit their health care providers for annual visits, which play a valuable role in patient care," said John C. Jennings, MD, president of ACOG, in a news release. "An annual well-woman visit can help physicians to promote healthy living and preventive care, to evaluate patients for risk factors for medical conditions, and to identify existing medical conditions, thereby opening the door for treatment. Annual well-woman visits are important for quality care of women and their continued health."

One coauthor reports receiving grants and other support from Informed Medical Decisions Foundation and grants and other support from Healthwise. The other authors, Dr. Cook, and Dr. Morgan have disclosed no relevant financial relationships.

Ann Intern Med. Published online July 1, 2014. Full text


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