Do you really need that annual pelvic exam?
The recent clinical guidelines and recommendations proposed by the American College of Physicians are saying you don’t. The ACP's latest recommendations call into question the need for performing the annual screening pelvic exam, which includes a speculum and bimanual exam. These recommendations have caused a great deal of confusion with patients and concern for us as women's health care providers.
The guidelines proposed were based on reviewing published literature looking at the value of the pelvic exam in asymptomatic women. Although based on published data, none of these studies addressed the accuracy of the pelvic exam for diagnosing pelvic inflammatory disease and gynecologic cancers, other than cervical cancer. In addition, fourteen of the studies included in this review were of low quality, but still were included.
The ACP addressed a number of concerns that can come as a result of annual pelvic exams, including overdiagnosis, overtreatment, fear, anxiety, embarrassment, and discomfort. Their guidelines also addressed the unnecessary costs of annual exams for a health care system. My concern with accepting these guidelines is that many women will be harmed in concluding that there is no value in the annual visit to the gynecologist if the pelvic exam isn't necessary. Traditionally, many women have thought that a pelvic exam was the sole purpose of the visit, but there are many other important aspects to an annual visit other than the pelvic exam.
Many women already put their own health last and often wait until serious symptoms begin to see a physician. Since symptoms tend to be subjective, they are easily ignored and often thought of as “asymptomatic.” We have seen this in women with delays in identifying heart disease and domestic violence.
These subjective symptoms need to be evaluated by every means available—including the pelvic exam.
As gynecologists, we have all discovered something concerning on these "routine" exams—serious conditions like breast cancer, vulvar and vaginal cancer, vulvar skin disorders, uterine cancers, and diseases of the colon and rectum. If these women had waited until they noticed their symptoms and had a pelvic exam, these would not have been discovered as early.
In the real world, we don’t wait for our cars to fail and become unsafe before we have a check-up, we don’t wait for the brake light or check engine light to have them examined. Airline pilots check their planes every flight, not just when the warning lights come on. Why should we accept less for our most precious loved ones—our mothers, wives, and daughters?
In conclusion, I believe that we should continue with annual visits to the gynecologist, and should discuss with each individual woman whether the pelvic exam is important and appropriate for her.
Gregory Bolton, MD is a gynecologist with Main Line HealthCare Gynecology at Lankenau Medical Center.