Pelvic Exams for Women May Be Unnecessary, Says ACP

Routine pelvic exams may cause some harm and little benefit according to the American College of Physicians

(RxWiki News) There is one procedure that has been part of a woman's routine exam but which may no longer be considered necessary or advisable.

The pelvic exam is a visual and manual examination of a woman's vulva, uterus, cervix, fallopian tubes, ovaries, bladder and rectum. According to new recommendations from the American College of Physicians (ACP), the pelvic exam may not be useful for many women.

In a just released guideline, the ACP concluded that in women without symptoms and who are not pregnant, the pelvic exam may be an unnecessary procedure.

"Ask your OB-GYN if you need a pelvic exam."

The clinical practice guideline was issued by a group of specialists led by Amir Qaseem, MD, PhD, MHA, FACP, Director of the Department of Clinical Policy at the American College of Physicians.

Dr. Qaseem and colleagues acknowledged that the pelvic exam has been part of a woman’s physical exam for decades. These researchers sought to find studies supporting the benefits of the exam, such as whether it is useful in detecting ovarian cancer.

They conducted a systematic review of studies on pelvic exams from 1946 until January 2014, using Medline and hand searching. There were 52 included studies.

Dr. Qaseem and team did not find any studies that identified reduced disease or deaths as a result of the pelvic examination, and most major professional and governmental groups recommended against routine pelvic screening.

The PLCO (Prostate, Lung, Colorectal and Ovarian) cancer screening trial looked at 78,000 women followed for an average of 12.4 years, and found pelvic screening using manual uterine palpation (feeling inside the uterus by hand) was initially used but dropped after five years because no malignant cancers were detected by this method alone.

The authors also noted that many women reported fear and embarrassment from the exam. Furthermore, 11 to 60 percent of women reported pain or discomfort from a pelvic exam.

Dr. Qaseem and team also mentioned that Medicare “National Payment Amount” values for 2013 were $38.11 for a single screening pelvic examination. This amounts to a significant sum if the majority of women have these exams and no benefits are proven.

These researchers noted that pelvic exams are not the same as Pap smears. Pap smears should still be done regularly in women 21 and older, they wrote, as Pap tests may help detect cervical cancer.

In an editorial accompanying this research, George Sawaya, MD, and Vanessa Jacoby, MD, MAS, from the University of California, San Francisco, noted a few problems with the guideline, such as that the authors did not look at whether pelvic exams were useful at detecting benign (noncancerous) tumors.

The editorial authors wrote that this recommendation may not be easily accepted. “Ending such a prevalent practice with widespread support among women’s health providers will be met with formidable challenges," they wrote.

They added that many physicians may uphold the practice even without proven benefits. “The pelvic examination has held a prominent place in women’s health for many decades and has become more of a ritual than an evidence-based practice," they wrote.

Andre Hall, MD, of Birth and Women’s Care in Fayetteville, North Carolina, told dailyRx News that he is a gynecologist who believes pelvic examinations are an important part of a complete physical examination.

“The guidelines in this publication explore circumstances that may allow for elimination of this important aspect of the female examination in asymptomatic patients. I believe the elimination of this part of the exam risks missing many benign and non benign conditions early in their course during a time that treatment is most effective.”

The guidelines and accompanying editorial appear July 1 in the Annals of Internal Medicine.

Financial support for the development of this guideline came from the ACP operating budget.

Review Date: 
June 30, 2014