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New Pelvic Exam Recommendations

Jul 1, 2014

New Pelvic Exam Recommendations Explained:

Yesterday the American College of Physicians released the results of a new study, published in the Annals of Internal Medicine, regarding PART of the annual Gyn exam that millions of women have every year. They reviewed over 50 studies dating back to the 1940’s to evaluate the risks versus the benefits of a yearly pelvic exam on non-pregnant, adult women who were not having any symptoms of pelvic disease. They found that the pelvic exam did not save lives, was a poor predictor of pelvic cancer or other non-serious gynecologic conditions, and was associated with fear, discomfort, embarassment, etc. Here’s what I want you to know about this Women’s Health news story:

Reassessing and reevaluating our practices in medicine is vitally important. It’s a good thing. We are always learning and revising. If a test is found to be low-yield, we should reassess whether or not we should do it. The pelvic exam is a good example of that practice, but it’s not black or white. First of all, I am a big believer in individualizing care, and using clinical judgement as well as guidelines and algorithms. Taking care of patients is not cookie-cutter, and it’s not one-size-fits-all. There are some patients who don’t need a pelvic exam every year, and others who do. In terms of screening for cancers and other pelvic pathology, if a woman is able to have sex without pain or bleeding, the chances that a pelvic exam will catch something that the woman herself hasn’t noticed before-hand are slim. And for that reason, for over a year, I haven’t been routinely doing pelvic exams on every one of my young, asymptomatic patients. On this basis, I think it’s a positive thing that the ACP undertook this meta-analysis regarding routine pelvic examinations.

There are, however, some problems with this new news. Firstly, these recs come from a group of Internists, not Ob-Gyns or Women’s Health Specialists. To me, that is analagous to my making a recommendation on cholesterol screening for heart disease just because I did a medical literature review. Cardiology is not my specialty, and while I make it a priority to know about how to screen women for cardiovascular disease, I defer to my Cardiology colleagues to make their appropriate recommendations. As such, the saying, ‘stay in your lane’ comes to mind. Last night, ACOG (the American College of Obstetricians & Gynecologists) issued a statement explaining that they continue to stand by their policy on pelvic exams. While they acknowledge that its use may not be evidence-based, they feel that it still has a role in the clinical judgement of a gynecologist and that it can and does serve some beneficial purpose in certain women. As a Board-certified Ob-Gyn, I make it a priority to know the ACOG policy statements on all aspects of Women’s Health care and then if I choose to deviate from these policies, I discuss that decision with my patients. I agree with ACOG’s position on pelvic exams. I do one when I feel it’s indicated or necessary, and I don’t when I feel it’s not indicated or necessary.

This brings me to the point of view of the woman. For years, I have been telling my patients that the screening test for cervical cancer (aka the Pap Smear) is not needed on an annual basis for young women with no history of abnormal paps. These are the new ACOG guidelines since 2012. I explain that the reason for this is that MOST of the time, cervical cancer takes more than 10 years to develop, and it progresses through stages of abnormal pap smear results. For that reason, and for the reason that over-diagnosing and over-treating minor abnormalities of the cervix is thought to do more harm than good. In 5 years and in my nearly 2000 patients, I do not have a SINGLE patient who is happy about this, agrees to less screening, or is comfortable with dialing back cervical cancer screening regimens. I also have two patients who developed cervical cancer within 2 years of having completely normal pap smears. No progression from mild to severe; no decades of neglect or missed visits. Normal pap one year- cervical cancer 2 years later. I don’t have one patient who is comfortable with less screening. Not one.

I also take issue with the often-attributed issues of ‘fear, anxiety, and embarrassment’ that are listed as possible harms or risks of a test or procedure. This paternalistic view or imposition of an emotion on a woman on behalf of a governing body of experts is out of place in our modern world of medicine and science. When I was a student at Columbia Medical School from 1996-2000, never did we hear an emotion listed as a possible risk of test or procedure. This new common practice of mentioning these emotions as reasons that doctors should not perform a test harkens back to a previous time where women were treated as the weaker sex, and coddled because of their perceived ‘fragility.’ It’s 2014 folks. I think that if a woman/patient has fear or anxiety about a test, she is capable of verbalizing those feelings for herself and it becomes the responsibility of her health care provider to educated, inform, assuage her concerns and decide WITH her whether to procede with the given test. I don’t feel that organizations should assume that women feel one way or another, even if 30% of women in this particular study did have those such emotions.

I’ve been taking care of women for 14 years. I chose to specialize in Ob-Gyn and Women’s Health because I find women to be stoic and proactive about their health and well-being. It is concerning to me, as a physician and as a woman, to see what appears to be a slippery slope of withdrawal of preventive health services for women: mammogram guidelines, cervical cancer screening guidelines, now pelvic exams...We have a much lower world ranking in Maternal Child Health parameters than we should given our medical system. I don’t want this ranking to deteriorate. Sending women a message that they don’t need this or that, and that we should avoid a test that is scary or uncomfortable is potentially putting women’s lives in jeopardy.

As a physician, on a daily basis I practice the premise of ‘first do no harm’ that is part of our Hippocratic Oath. I also carefully weigh the risks of doing a test, versus the risks of NOT doing the test, as well as the benefits of doing it vs the benefits of NOT doing it. This is second nature to me, and I pride myself on this practice because I believe that it enables the best care of my patients. In experienced hands, performing a pelvic exam should be neither painful nor generate excessive false-positives. Many Ob-Gyns consider it to be an integral part of the annual exam, which also includes talking the patient, and visually inspecting the lower genital tract. The ACP recommendations fail to take into account the practice of the recto-vaginal exam in which the posterior cul-de-sac (part of the pelvis) is examined for masses (potentially cancer, ovarian cysts or fibroids). It also lumps the speculum exam (during which time we visually inspect the vagina and cervix) with the pelvic exam; these procedures can be uncoupled and often are. A woman can have one without the other. Practicing Gyns or Family Practitioners know this. Perhaps Internists don’t.

For now, I want women to understand that they are in charge of their bodies and their health; not a governing body of experts. They should feel comfortable discussing these news stories with their health care provider, and if they don’t, they should find one who makes having these discussions easier. Our health depends on it.

Jennifer Ashton, M.D., F.A.C.O.G.

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Jennifer Ashton MD