Edward C. Geehr, M.D.

Should pelvic exams be included in women's yearly physicals?

A controversy is brewing about that subject among two doctors' groups.

The American College of Physicians (ACP), whose members are internists, recently recommended that doctors stop performing pelvic exams during routine checkups on healthy women.

The American College of Obstetricians and Gynecologists (ACOG), on the other hand, has reasserted the importance of regular pelvic examinations. The outcome of the disagreement could influence primary-care medical practice and affect insurance coverage decisions.

A clinical practice guideline developed by the ACP – published recently in the Annals of Internal Medicine – recommends against performing pelvic examination in asymptomatic, non-pregnant adult women. The guideline is based on a review of published research articles on the effectiveness of pelvic examination from 1946 through January 2014. The physician's group evaluated outcomes that include death, co-existing medical conditions, over-diagnosis, over-treatment, fear, anxiety, embarrassment, pain and discomfort.

To arrive at their conclusion, the researchers addressed three basic questions from the 68 years of data studied. They included:

1. How accurate is the screening pelvic examination for detecting cancer, pelvic infections or other benign gynecologic conditions?

2. What are the benefits and harms of the pelvic exam performed for the detection of cancer (other than cervical), pelvic infections or other gynecologic conditions?

3. What are the examination-related harms and possible benefits of performing the examinations in women with no symptoms?

Results showed that the diagnostic accuracy of routine pelvic examinations for detecting ovarian cancer or pelvic infections in healthy women was low. Pelvic exams rarely detected non-cervical cancers or other treatable conditions and were not associated with improved health outcomes.

Nor was there any reduction in ovarian cancer death rates as a result of screening with pelvic examinations or transvaginal ultrasound, considered more sensitive than the pelvic exam alone.

None of the studies reviewed by the ACP researchers addressed the diagnostic accuracy of routine pelvic examination for other conditions such as pelvic infection, benign tumors (fibroids), or gynecological cancer, other than ovarian or cervical.

The study also identified many false-positive results associated with pelvic examination. They can lead to psychological and physical harms, such as unnecessary laparoscopies, fear, anxiety, embarrassment and pain. Women who have experienced sexual violence may be more vulnerable to psychological trauma during the exam.

ACOG agrees that routine pelvic exams aren't useful for ovarian cancer screening. But it points out that experienced physicians are able to identify other problems, such as fibroid tumors, urinary incontinence and sexual dysfunction, which might go undetected without a routine pelvic exam. The absence of evidence, ACOG points out, is not the same as providing no value.

The study in no way downplays the importance of cervical cancer screening, which requires a pelvic examination. The benefits of such screening are well documented and life-saving. In this instance, however, the ACP recommends that when screening for cervical cancer, the pelvic exam should be limited to a visual inspection of the cervix and cervical swabs for cancer and human papilloma virus and not include a manual inspection of the uterus and ovaries.

The ACP guideline will lead to much debate and further analysis of the value of routine pelvic examinations. Meanwhile, women should consult with their physician about whether the routine exam is appropriate for them.