Commentary Argues It Deters Regular Gynecological Care
Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.
Many women find it embarrassing, invasive and even painful. And being instructed to "relax" frequently has the opposite effect.
Now, a commentary in the January Journal of Women's Health has raised a provocative argument: For healthy women with no symptoms of disease, a routine pelvic exam serves little purpose—and may be so disliked that it dissuades some women from getting regular gynecological care.
"If a woman is asymptomatic and feeling fine, getting naked on a table with stirrups and a speculum is not adding extra value," says lead author Carolyn Westhoff, a professor of Obstetrics and Gynecology at Columbia University Medical Center and of epidemiology at the Mailman School of Public Health. "We should be talking about diet and exercise and immunizations—and having time to listen to what she's worried about. We can let go of something that is uncomfortable and embarrassing and not that useful."
In fact, the American College of Obstetricians and Gynecologists (ACOG) is re-evaluating its recommendations on the subject. "We are looking at this very closely," says Cheryl Iglesia, chair of ACOG's Committee on Gynecologic Practice.
Traditionally, a key reason for doing a pelvic exam has been to take a Pap smear—a sample of cells on the cervix to check for signs of cervical cancer—long recommended annually. But in late 2009, ACOG revised its recommendations for Pap smears to every two years for women ages 21 and 30 with no symptoms or other risk factors, and every three years from 30 and older.
Given that change, ACOG is rethinking other elements of the annual exam as well, says Dr. Iglesia. "There may be times when [a pelvic exam] is not necessary and your 15 minutes of managed-care time may be better spent talking."
What's in a Pelvic Exam?
Some of the checks done in routine visits may be done by other means.
Cervical cancer. Annual pap smears that sample cervix for abnormal cells have helped reduce cervical cancer significantly; ACOG now recommends them every two years from ages 21 to 30; every three years after that for women with no health issues.
Ovarian cancer. Odds of survival are much greater when diagnosed early, but studies show that the bimanual check is not effective in finding Stage 1 cancers.
Fibroids, cysts, endometriosis. Many of these can be felt with a bimanual exam before they cause symptoms, and early intervention can stave off fertility problems and pain. But sonograms provide more detailed information and many such abnormalities resolve on their own.
Sexually transmitted diseases. Can be detected via urine or blood tests or self-administered swabs, but some are asymptomatic so women may not know to be tested outside of a routine pelvic exam.
Contraception. Pelvic exam is needed to insert an IUD or fit a diaphragm but isn't necessary for prescribing pills or patches.
Visual exam of vagina, uterus, external organs. Can provide information on injuries, hormone levels, cancers and other issues not available otherwise.
Source: Journal of Women's Health, January 2011; WSJ reporting
In addition to the Pap smear, an ob-gyn also traditionally uses a pelvic exam to check the ovaries and uterus for signs of cancer. The ob-gyn uses two fingers to palpitate the organs inside while pressing on the patient's abdomen from the outside, the so-called bimanual exam.
But Dr. Westhoff and her co-authors point out that bimanual exams don't lead to earlier diagnoses of ovarian cancer and aren't recommended for that purpose by ACOG, the American Cancer Society or the U.S. Preventative Service Task Force. They are seldom performed in the United Kingdom, where the proportion of women diagnosed with Stage 1 ovarian cancers is the same as in the U.S.
Bimanual exams do sometimes lead to additional tests and procedures, such as having ovarian cysts or fibroids removed that may have resolved on their own, says Dr. Westhoff, who notes that one reason ACOG moved away from annual Pap smears was that abnormalities seen there sometimes led to laser excisions or biopsies that could harm a patient's fertility unnecessarily. When women do have symptoms, such as abdominal pain, backache or irregular bleeding, ultrasounds can reveal more information than palpitation can, she adds.
Pelvic exams are also commonly used to screen for sexually transmitted diseases and before prescribing contraceptives. But the authors note that chlamydia and gonorrhea can be detected just as well via blood or urine tests or with swabs that women can administer themselves. And while a pelvic exam is needed to fit a diaphragm or insert an intrauterine device for birth control, there's no need for one before prescribing the pill or a patch.
"I don't want a young woman to be afraid to come in for contraception because she's afraid she'll get a pelvic exam," says Dr. Westhoff. "The pelvic exam is irrelevant to starting the pill. But a substantial portion of doctors still require one. I think a lot of them have just been taught that that's the thorough way to take care of patients, and nobody has stopped to ask, 'What are you looking for?' "
Some other ob/gyns say a pelvic exam can provide numerous clues to a patient's condition. "There's a treasure trove of information you can glean from a pelvic exam," says Laurie Green, a San Francisco ob/gyn.
For one thing, Dr. Green says she can gauge roughly how close a woman is to menopause from the color of her vaginal walls, and says she has occasionally spotted malignant melanomas. She has also spotted cancers during the rectal portion of the exam, and cervical polyps that can make intercourse painful.
Bimanual exams can sometimes detect early stages of endometriosis, an overgrowth of uterine lining outside the uterus, and fibroids that may be asymptomatic now but can pose problems later. "I've had patients who get pregnant and they come in with massive fibroids, and if the fibroids had been removed earlier, they would have a much lower risk for preterm labor," says Dr. Green. "You would lose all of that if you didn't do a pelvic exam."
And while many women detest the pelvic exam, some consider it a crucial part of the visit. Mary Jane Minkin, a professor of ob/gyn at Yale University School of Medicine, says that with the older women she sees in her private practice, "I'm discussing their general health, health habits, weight, exercise regimens, smoking, sexual issues—all of it important—but what sanctifies the visit is the pelvic exam."
Without it, she wonders, "Would they really come in regularly for the health counseling and would insurance reimburse for it?"
Another issue is litigation, Dr. Minkin says. "If something could have been picked up on a pelvic exam and a pelvic wasn't done, do we get sued?"
Dr. Minkin also cautions that while women in monogamous relationships aren't at high risk for cervical cancer, some women only think their relationship is monogamous, so an annual check provides additional protection.
Whether it's done every year or less frequently, a pelvic exam is still necessary periodically, and some doctors, at least, are focusing on ways to make it less uncomfortable for patients.
Robert Reid, a professor of ob/gyn at Queens University in Kingston, Ontario, has developed a video giving medical students more guidance on how to give a "compassionate" pelvic exam. The tips include warming the speculum and testing it on a patient's skin first as well as explaining every step so there are no surprises.
"This is from over 30 years of watching novices make mistakes," he says. The video has been adopted by Canada's Association of Professors of Obstetrics and Gynecology, which distributes it to all Canadian medical schools, and it will be demonstrated at a conference of U.S. ob/gyn professors in San Antonio next month.
Write to Melinda Beck at HealthJournal@wsj.com
I am, of course, offended and enraged that the justifications for exams are money, fear of litigation, and that it "sanctifies" the visit. What the hell? I would also argue against the idea of a pelvic exam being "necessary periodically," unless it is to evauate symptoms. If it's not necessary, it's not necessary, period.
"Many doctors require that women have a pelvic exam before they can get a prescription for birth control pills, despite guidelines saying that the step is unnecessary, a new study finds[....]Overall, 29 percent of ob-gyns and 33 percent of family doctors said they always required a pelvic exam for women seeking birth control pills. In addition, half of ob-gyns and about 45 percent of family doctors said they usually required the exam. Advanced-practice nurses specializing in women's health were the least likely to require a pelvic exam, with 16 percent saying they always did so. In contrast, nurses specializing in family medicine were more likely than all other providers to always require a pelvic exam; 45 percent said they did."
I would have guessed, from people reporting here at VP and elsewhere, that the actual percent of doctors requring (or at least, appearing to require) pelvic exams before precribing HBC is actually much higher than above. What I don't understand is, where's the outrage? Why do I feel like I'm the only one furious about the unnessary hurdles placed on people seeking birth control? It has eroded what little trust I ever had for the medical profession (since more health care providers really ought to be speaking out against it) and made me feel as if I have to be adversarial and hyper-viligant any time I need any sort of health care.