COMMENTARY

What? No More Annual Pelvic Exams?

Sandra Adamson Fryhofer, MD

Disclosures

August 20, 2014

Sandra Adamson Fryhofer, MD
Adjunct Associate Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia; Past President, American College of Physicians

No More Routine Pelvic Exams...Really?

I am a female general internist. I provide well-woman screening -- including "the" pelvic exam -- for the vast majority of my patients. That's why new clinical practice guidelines from the American College of Physicians (ACP),[1] based on a comprehensive systematic review of 68 years' worth of English-language evidence, really caught my eye. I read ACP's strong recommendation: "ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women." My first thought was, "Really?" Next to mind was, "Controversial!"

Personal Disclosure: My Family History

My mom had ovarian cancer in her 40s. At the end of my second year of medical school, the evening after day 2 of my medical boards, my mom shared the bad news. She woke up in the middle of the night with abdominal pain. She went to the doctor and was told her ovaries were the size of footballs. She had a hysterectomy in which her uterus was removed, but not her ovaries. I'm not sure why. No one ever told her she needed to get her ovaries checked.

Surgery did reveal stage I, bilateral ovarian cancer. Pathology reports said it had not yet spread. But because of the large size of her ovaries and concern about micrometastases, her doctor decided to give her intra-abdominal radioactive phosphorus implants.

That was 22 years ago. My mom is still living, and her ovarian cancer has not returned.

Read the Fine Print: "Asymptomatic"

The fine-print details are key to understanding how this new recommendation applies to clinical practice. It only applies to women who are not pregnant. It only applies to asymptomatic women. Women with NO symptoms: no vaginal discharge, no pain, no abnormal (or unexpected) bleeding, no urinary problems, and no sexual dysfunction. Women who have symptoms still need a pelvic exam. The recommendation only applies to average-risk women.[1]

Fine-Tuning What Is Needed and What Is Not

Seeing this recommendation in black and white, published in the Annals of Internal Medicine, was surprising for me. But it is also consistent with the new wave of improving care and eliminating unnecessary tests and procedures, in the spirit of American Board of Internal Medicine's Choosing Wisely® campaign.[2] Let's face it: The time we have with patients is precious. We need to make the best use of it.

Change Is Happening Anyway

The value of a yearly pelvic exam seems logical. Conversely, seeing this recommendation in black and white could appear somewhat radical. But is it?

We've already been making baby steps in this direction. A pelvic exam is no longer required before prescribing oral contraceptives.[3] Because of new technologies and techniques, a pelvic exam is no longer required to screen for Chlamydia, bacterial vaginosis, or gonorrhea. These can be done with a urine test or self-collected swab.[3]

Pap smears (cervical cytology for cervical cancer screening) are no longer required annually. The current American College of Obstetricians and Gynecologists (ACOG) recommendation is to start cervical cancer screening at age 21 years, then screen at most every 3 years, with no cervical cancer screening after age 65 years.[4] Do understand: Regular cervical cancer screening is still "in," but the new recommendation says that the bimanual exam (for routine screening) is "out."[1]

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