Many providers continue unnecessary pelvic exams
Do you use a pelvic exam to screen for sexually transmitted infections, check for ovarian and other gynecologic cancers, or determine whether women should receive hormonal contraceptives? If so, your practice is not supported by scientific evidence and is not recommended by any U.S. organization, according to newly published research.1
The research, which includes the result of a recent nationwide survey, show many providers continue to perform pelvic exams in such circumstances, even though such practices are not evidence-based. What prompted the investigators to look at the practice of pelvic exams among U.S. providers?
The routine pelvic exam has been considered as a central component of well-woman visits for many decades, says Analia Stormo, a research fellow at the Centers for Disease Control and Prevention (CDC) and lead author of the current investigation. It is only recently that health officials have started to gather evidence to examine the benefits and harms of various tests and procedures, including the pelvic exam, she states. "Given the growing body of evidence questioning the value of performing pelvic exams as a screening tool among asymptomatic women, we thought it was important to examine these practices, as they had remained unexplored for many years," says Stormo. "This issue is more salient than before because annual cervical cancer screening is being actively discouraged by many organizations, while well-woman visits are being supported."
Look closer at study
In conducting the survey, Stormo and colleagues from the CDC's Division of Cancer Prevention and Control and researchers from the Soltera Center for Cancer Prevention and Control Research, Tucson, AZ, analyzed data from the 2009 DocStyles survey of 1250 U.S. internists, family practitioners, general practitioners, and obstetrician/gynecologists (OB/GYNs). Providers were questioned whether they performed pelvic examinations for each of the following reasons: ovarian cancer screening, other gynecological cancer screening, as a requirement for starting oral or hormonal contraception, to screen for sexually transmitted infections (STIs), or as part of a well-women exam.
What did the researchers learn? More than half of all physicians reported conducting routine pelvic exams as part of a well-woman exam, with 98.4% of obstetrician/gynecologists reporting such practice, compared to 89.5% of family practitioners/general practitioners (FP/GPs) and 54.0% of internists. In the case of ovarian cancer screening, routine pelvic exams were reported by 95.2% of OB/GYNs, 55.2% of FP/GPs, and 29.7% of internists; for screening for other gynecological cancers, the percentages were 96%, 68%, and 41.2%, respectively. More than 90% of OB/GYNs said they routinely performed such exams to screen for STIs, compared to 72.9% of FP/GPs and 39.9% of internists.
Where's the evidence?
It is not surprising that most OB/GYNs perform routine pelvic exams, given that the American College of Obstetricians and Gynecologists includes pelvic examinations as a component of periodic assessments for women ages 21-64.2 However, the guidance states that it is reasonable to discontinue pelvic examinations "when a woman's age and other health issues are such that she would not choose to intervene on conditions detected during the routine examination."2
Many providers said they performed a routine pelvic examination as a screening test for ovarian cancer in asymptomatic women; however, it is unlikely that such an examination has value, points out George Sawaya, MD, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, in an accompanying commentary.3 Sawaya points to results from a recent randomized trial of 78,216 women ages 55 to 74, which demonstrated that screening with CA-125 and pelvic sonograms (a practice more accurate than bimanual examinations) are ineffective in preventing ovarian cancer mortality.4
"The high percentage of OB/GYNs who continue to use pelvic examinations to screen average-risk women for ovarian cancer is particular cause for concern, given that an estimated 98% of positive screening results among such women are false positives," state Stormo and her colleagues.
Exam for contraception?
Hormonal oral contraception can be prescribed safely without a pelvic examination, according to guidelines from the World Health Organization and the American College of Obstetricians and Gynecologists.5,6 Screening for such STIs as chlamydia can be performed with lab tests.
Requiring women to undergo pelvic exams to check for STIs or before prescribing hormonal contraceptives might discourage women from seeking needed birth control or deter them from routine screening for STIs, write Stormo and colleagues.
In his commentary, Sawaya calls for future studies to focus on defining the potential benefits and harms of the pelvic examination in asymptomatic women.
"In the absence of direct evidence of benefits and harms, a thoughtful decision analysis of various aspects of the examination (i.e., inspection of the external genitalia, speculum examination, bimanual examination) including potential benefits (e.g., identifying neoplastic vulvar/vaginal lesions, identifying benign ovarian lesions that may cause medical emergencies such as rupture and torsion) and harms (e.g., complications due to false-positive testing results) would be useful," writes Sawaya. "Given plausible outcomes, clinicians should not be surprised if the examination is deemed to be more harmful than beneficial and ultimately is discouraged as part of a well-woman exam."
References
- Stormo AR, Hawkins NA, Cooper CP, et al. The pelvic examination as a screening tool: practices of US physicians. Arch Intern Med 2011; 171:2,053-2,054.
- American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 483: Primary and preventive care: periodic assessments. Obstet Gynecol 2011; 117:1,008-1,015.
- Sawaya GF. Pelvic examinations in asymptomatic women: tipping a sacred cow: comment on "the pelvic examination as a screening tool". Arch Intern Med 2011; 171:2,054-2,055.
- Buys SS, Partridge E, Black A, et al; PLCO Project Team. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA 2011; 305:2,295-2,303.
- Henderson JT, Sawaya GF, Blum M, et al. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol 2010; 116:1,257-1,264.
- World Health Organization. Selected Practice Recommendations for Contraceptive Use. Second ed. Geneva: WHO; 2004. Available at http://whqlibdoc.who.int/publications/2004/9241562846.pdf.
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