Obstetrician–Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women

Amy Hsu, MD; Jillian T. Henderson, PhD, MPH; Cynthia C. Harper, PhD; George F. Sawaya, MD


J Am Geriatr Soc. 2016;64(2):293-298. 

In This Article

Abstract and Introduction


Objectives: To understand obstetrician–gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span.

Design: National survey from May 2010 to January 2011 asking obstetrician–gynecologists about the need for and importance of external inspection and speculum examination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations.

Setting: Mail-in survey of a national sample of obstetrician–gynecologists.

Participants: Probability sample of obstetrician–gynecologists from the American Medical Association Physician Masterfile (N = 521).

Measurements: Proportion of obstetrician–gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important.

Results: The response rate was 62%. In a healthy 70-year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very important in the 70-year-old (63%) than in younger women (46–53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care.

Conclusion: Obstetrician–gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.


Approximately 62.8 million pelvic examinations were performed in the United States in 2010.[1] Current recommendations regarding the appropriateness of pelvic examinations in asymptomatic older women are inconsistent. In August 2012, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion (reaffirmed in 2014) stating that it would be reasonable to stop performing pelvic examinations when a woman's age or other health concerns reached a point at which she would not choose to intervene on conditions detected during the routine examination.[2] Women who have undergone a total hysterectomy and bilateral salpingo–oophorectomy for noncancer diagnoses and are asymptomatic should continue external examination but can decide whether to receive an internal examination. ACOG acknowledged that no evidence supports or refutes performing an annual pelvic examination in asymptomatic, low-risk women. In contrast, the American College of Physicians (ACP) recommends against performing screening pelvic examinations in asymptomatic, nonpregnant women based on a systematic review that reported lack of benefit and potential for harm.[3] Despite the lack of evidence for performing pelvic examinations in older women who are asymptomatic and in women who have undergone total hysterectomy and bilateral salpingo–oophorectomy, many physicians continue to perform screening pelvic examinations in these women.

The pelvic examination includes three components: inspection of the external genitalia (vulva, urethral meatus, vaginal introitus, perianal region); speculum examination of the vagina and cervix; and bimanual examination of the uterus, cervix, and adnexa. Physician practices and beliefs on the bimanual examination component of the pelvic examination have previously been reported.[4] Little is known about the clinical circumstances under which clinicians perform external genitalia inspection and speculum examinations in asymptomatic women with no clinical indication for cervical cancer screening or testing for sexually transmissible infections. Understanding these clinical circumstances can guide education to reduce unnecessary screening pelvic examinations and direct the focus of future research to areas in which more evidence is needed. This report analyzes obstetrician–gynecologist survey responses to four clinical vignettes on their practices and beliefs regarding these examination components in asymptomatic women. Responses to vignettes regarding healthy older and younger women are compared.