COMMENTARY

The Routine Pelvic Exam: A Gynecologist's Perspective

Andrew M. Kaunitz, MD

Disclosures

July 09, 2014

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In a recent issue of Annals of Internal Medicine,[1,2,3] the American College of Physicians (ACP) recommends against performing routine pelvic examinations as part of well-woman visits.

Women and clinicians view vaginal speculum and bimanual examinations as a key component of the well-woman visit. Now, the ACP has issued evidence-based guidance contesting this time-honored practice. The ACP's review indicates that routine pelvic examination is not useful in screening for malignancies other than cervical cancer, may generate unnecessary evaluation and surgery, frequently causes discomfort and embarrassment, and may prevent some women from receiving gynecologic care.

The ACP's recommendation to not perform routine pelvic examination in asymptomatic, nonpregnant adult women does not apply to cervical cancer screening. The ACP recommends that such screening 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.

In 2012, the American College of Obstetricians and Gynecologists (ACOG) recommended that speculum and bimanual examinations be performed during annual well-women visits in patients aged 21 and older.[4] In adolescents and other women who may find pelvic examinations emotionally stressful, I agree with the new ACP guidance that not performing routine pelvic examinations is appropriate. I also agree that pelvic exams are not an effective screening test for ovarian cancer.

However, during adult well-woman visits, I routinely encounter vulvovaginal atrophy, lichen sclerosus, bacterial vaginosis, mucopurulent cervicitis, cervical polyps, and pelvic prolapse in women who had not reported symptoms prior to their examination.

These observations underscore the clinical value of routine pelvic examinations, and suggest that the published literature assessed by the ACP fails to address many relevant outcomes related to pelvic examination. Most of my adult patients continue to expect routine pelvic exams, and I plan to continue to perform them as part of well-woman visits.

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