Pelvic Exams

Women over the age of 21 know what THIS is all about.  You go to the gynecologist or your primary care doctor for birth control or for your annual checkup.  After a zillion questions and the typical heart-lungs-belly exam the doc pulls out those lovely things for you to put your feet into and invites you to “Come on down!”

After scooting your bottom down (your NAKED bottom) until you feel like you’re going to fall right off into your doctor’s lap, the doctor proceeds with the annual two-part indignity of Pap test and pelvic exam.

The Pap test involves inserting a speculum (used to let him or her see your cervix) and taking a sample of cells from the surface of the cervix.  The bimanual exam has the doctor putting one or two fingers inside the vagina and the other hand on the abdomen to assess the size and position of the uterus and ovaries.

What if I told you half of that exam wasn’t necessary?

In March of this year, the United States Preventive Services Task Force issued a summary recommendation stating there is not enough information to recommend for or against the bimanual pelvic exam as a screening test.

I admit I had to stop and think about that one.  I was taught in school to do a pelvic exam every time I do a Pap test, but when I stopped to think I realized that I have never found a true problem in a woman who has no symptoms.

What symptoms might a woman have that indicate a potential problem in their pelvic organs?  Pain, of course.  Heavy or irregular menstrual periods.  Bothersome vaginal discharge.  In those cases, the pelvic exam is a useful part of the diagnostic process.

However, how often do we find problems in patients who have no symptoms at all?  Studies have shown that doctors actually are pretty lousy at telling the difference between a normal exam and an abnormal one.  We tend to find problems that aren’t actually there.

One analysis of three different studies looking at pelvic exams’ accuracy in finding ovarian cancer showed that 96-100% of abnormal pelvic exams actually had no abnormality identified.  The doctor felt something and ordered a test (usually an ultrasound or CT scan).  The test showed no evidence of ovarian cancer.

So if pelvic exams are not terribly accurate in identifying ovarian cancer, are they harmful?  Yeah, actually, they can be.  In studies, up to 60% of women reported physical pain and discomfort with the exam.  Up to 80% of women reported fear, embarrassment and anxiety.  Also, women who have a negative experience (because of pain or fear) are much less likely to return to the doctor for a repeat exam.  Obese women are more likely to report a negative experience and are much less likely to have an accurate exam, because of the difficulty of performing the exam.

There are more serious harms too.  There was a study that showed 1.5% of patients who had a pelvic exam wound up with unnecessary surgery for a concern about ovarian cancer.

The USPSTF states that there is not enough evidence to recommend for or against pelvic exams.  However, the American College of Physicians and the American Academy of Family Physicians have made recommendations that pelvic examinations NOT be performed in women who have no symptoms and have no increased genetic risk of ovarian cancer.

What does that mean for female patients?  You need to see your doctor regularly for screening exams based on your age, which may include a mammogram, Pap test, colonoscopy and blood tests.  However, the doctor performing a pelvic exam shouldn’t be part of the visit unless you’re having symptoms.

QUESTION:  Will you be more likely to get regular physicals if you know you won’t have to have a pelvic exam?


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