Howard LeWine, M.D.

Expert panel says healthy women don’t need yearly pelvic exam

The annual pelvic exam, an oft-dreaded part of preventive care for women, may become the as-needed pelvic exam, thanks to new guidelines from the American College of Physicians.

As part of a pelvic exam, a doctor uses a tool called a speculum to look at the vagina and cervix. She or he also inserts two fingers in the vagina and places her or his other hand on the outside of the stomach. The exam lets the doctor examine the cervix, uterus, and both side of the lower abdomen where the ovaries and Fallopian tubes are located.

For decades, doctors have believed this exam may detect problems like ovarian cancer or a bacterial infection even if a woman had no symptoms. And sometimes it does. But recently experts have questioned whether the yearly ritual adds value to a woman’s health.

In the new guidelines, published in the Annals of Internal Medicine, an expert panel appointed by the American College of Physicians recommends that healthy, low-risk women not have routine annual pelvic exams. The panel based this advice on a systematic review of prior studies. They not only found no benefit from the annual pelvic exam, they found that it often causes discomfort and distress. Sometimes it also leads to surgery that is not needed.

The new guidelines only apply to the pelvic exam, and only in healthy women. The panel urged women to keep getting checked for cervical cancer. Also, the experts emphasized that pelvic exams remain a necessary part of the evaluation in any woman with symptoms that could be related to a problem with the vagina, cervix, uterus, Fallopian tubes, or ovaries.

It’s also important to note that the American College of Obstetricians and Gynecologists still recommends a yearly pelvic exam for women, even though it acknowledges that the evidence does not support or refute its value.

Mixed feelings

Phasing out the annual pelvic exam mirrors a similar change for men. Doctors once routinely did rectal exams to check the prostate gland, a common site of cancer in men. But evidence that it isn’t a very effective way to detect prostate cancer, and may have caused more harm than good (sound familiar?) led experts to recommend against it being done every year.

I have to admit that as a doctor and as a man, I was happy about that change. I called a couple of my female physician colleagues to get their personal and professional reactions to the news about phasing out routine pelvic exams. Question: “Will you miss not having regular pelvic exams?” Response (paraphrased): “Are you serious? No way will I miss them!”

We did agree, though, that some women will feel that their annual check-up is not complete without a pelvic exam, just as some men do about the rectal exam. And some doctors will find it difficult to stop doing these exams, since they learned these rituals in medical school and were told they were beneficial.

A test women do need

Although seemingly healthy women may not need a pelvic exam every years, being tested regularly for cervical cancer can save a woman’s life. Here are the recommendations for women at average risk of cervical cancer:

  • ages 21 to 29: a Pap smear once every 3 years.
  • ages 30 to 65: a Pap smear every 3 years or a combination of a Pap smear and HPV test every 5 years.
  • over age 65: routine Pap screening not needed if recent tests have been normal.

Keep in mind that these are guidelines. For personal reasons, you and your doctor may wish to choose HPV testing first or have more frequent Pap smears than recommended.

If during a routine appointment your doctor wants to perform a pelvic exam, and you aren’t keen on the idea, feel free to ask why you need it and what he or she is looking for. That’s not a challenge. Based on current evidence, there should be a reason for doing a routine pelvic exam.

Related Information: Harvard Women’s Health Watch

Comments:

  1. agen celana hernia

    thanks you
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  2. EEB (Aust)

    “5 HPV primary or women can reliably self-test”

    I should have mentioned the 5 HPV primary tests or self-tests under the new Dutch program will be offered at ages 30,35,40,50 and 60. Pap testing does not benefit those under 30, but this group produce the most false positives. Not one country in the world has shown a reduction in the incidence or mortality of cc in those under 30, despite extensive screening. (but young women produce the most false positive which can lead to excess biopsies and over-treatment which can damage the cervix and lead to miscarriages, premature babies, the need for c-sections and cervical cerclage etc.)

    The Finns have the lowest rates of cc in the world and refer FAR fewer women for biopsies etc. Since the 1960s they’ve offered 7 pap tests, 5 yearly from 30 to 60, so this is not new evidence. The HPV test should not be used by those under 30 as about 40% would test HPV+… transient and harmless infections that will clear by age 30. It’s the 5% who test HPV+ at age 30 or older that have a small chance of benefiting from a 5 yearly pap test.

  3. EEB (Aust)

    Actually I’d also, question the need for pap tests, most women are HPV- and cannot benefit, but can certainly be harmed by false positives, excess biopsies and over-treatment. As an Australian women the routine pelvic exam was scrapped long ago, I always refused it anyway, it didn’t take much research to see it was of poor clinical value and carried risk.

    I don’t have pap tests either, an informed decision. It’s shameful that women are pressured and coerced into this elective screening test. Informed consent is a legal right. (coercion negates all consent and is a very serious matter) Too many make a fortune trying to drag all women into pap testing (and often serious over-screening) and all the excess that follows false positives. Here the lifetime risk of cc is 0.65%, always rare here and in natural decline before testing even started, while the lifetime risk of referral for colposcopy and usually at least a biopsy under our program is a hidden and horrifying 77%.
    The Dutch follow the evidence and put women first, they’ll scrap their 7 pap test program, 5 yearly from 30 to 60 and offer instead 5 HPV primary or women can reliably self-test with the Delphi Screener, and only the roughly 5% who are HPV+ will be offered a 5 yearly pap test. (until they clear the virus)
    This will save more lives (including cases of adenocarcinoma) and take most women out of pap testing and harms way.
    The awful over-screening we see in the States, Australia and elsewhere is a great business model, but bad medicine. Using the pap AND HPV test together simply generates the most over-investigation for no additional benefit to women. The continued need to control women needs to be addressed, the Pill should be taken off script, unnecessary barriers to access carry far greater risks to our health. (and lives)
    This consult has been used to take advantage of women, to mislead, coerce or pressure women to screen, that needs to stop. Are men “required” to have a rectal exam or colonoscopy before they can buy condoms or get a script for Viagra?

    Women need to be so careful, we cannot trust a system that puts their profits ahead of our health and legal rights. The routine rectal, recto-vaginal, breast and pelvic exams are not evidence based and are far more likely to harm us. I would never permit any of them, none are recommended here anyway.
    I have also, declined breast screening, in my opinion, the risks exceed any benefit. The Nordic Cochrane Institute, an independent, not-for-profit, medical research group, has produced an excellent summary of all of the evidence, it’s concerning. About 50% of screen detected breast cancers are over-diagnosed and any benefit of screening is wiped out by those who die from lung cancer and heart attacks after treatments.
    Too many are protecting screening and excess for their benefit, when we should always put the patient’s welfare first. What was the motto? First do no harm. How did we get so far away from that?

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