ACP Guideline Recommends against Pelvic Exam in Healthy Women

Pelvic examination is often conducted in asymptomatic women to screen for pathology. Many women and clinicians believe that pelvic examinations should be part of annual wellness visits, but a review of current evidence from the American College of Physicians (ACP) showed that the harms outweigh any demonstrated benefits. Based on the analysis, ACP published a new evidence-based clinical practice guideline [Ann Intern Med. 2014;161(1):67-72].

The guideline is based on a systematic review of the published literature in the English language from 1946 to January 2014. The evidence review was conducted by the Minneapolis Veterans Health Care System’s Evidence-based Synthesis Program Center to address the following questions:

1. How accurate is the screening pelvic examination for detection of cancer (other than cervical), pelvic inflammatory disease, or other benign gynecologic conditions?

2. What are the benefits (reduced mortality and morbidity rates) and harms (overdiagnosis, overtreatment, or diagnostic procedure-related) of the routine screening pelvic examination performed for the detection of cancer (other than cervical), pelvic inflammatory disease, or other benign gynecologic conditions?

3. What are the examination-related harms and indirect benefits of performing screening pelvic
examinations in asymptomatic women? Do these harms vary by patient or provider characteristics?

With the current evidence, ACP concluded that performing a pelvic examination exposes women to unnecessary and avoidable harms with no benefit. ACP recommends against performing screening pelvic examinations in asymptomatic, nonpregnant, adult women. The guideline does not apply to Pap smear screening.

ACP found that the diagnostic accuracy of the pelvic examinations for detecting ovarian cancer or infections is low. The PLCO [Prostate, Lung, Colorectal` and Ovarian] trial and cohort studies showed that the screening pelvic examination rarely detects noncervical cancer and other treatable conditions and was not associated with improved health outcomes. Furthermore, the PLCO trial found no reduction of ovarian cancer mortality rates by screening for pelvic examination or by screening with CA-125 or transvaginal ultrasonography.

When screening for cervical cancer, ACP recommends that the examination be limited to visual inspection of the cervix and cervical swabs for cancer and human papillomavirus and should not include the full pelvic examination. ACP advises that the pelvic examination is appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.

Screening for sexually transmitted disease can be performed with urine testing or vaginal swabs since they have shown to be highly specific and sensitive, and this technique is supported by several organizations. Many clinicians require a pelvic examination before prescribing oral contraceptives, although ACP found this practice is low-value care and not supported by evidence. ACP advises that clinicians consider omitting screening pelvic examinations for patients seeking oral contraceptives.

ACP also found evidence of screening pelvic examinations exposing asymptomatic, nonpregnant, adult women to unnecessary and avoidable harms, including fear, anxiety, embarrassment, pain, and discomfort, and possibly prevents women from receiving necessary medical care. In addition, false-positive screening results can lead to unnecessary laparoscopies and laparotomies.

These examinations add to unnecessary costs to the healthcare system. The total annual cost of preventive gynecologic examinations and associated laboratory and radiologic services in the United States is estimated at $2.6 billion. In 2013, Medicare payments were $38.11 for a screening pelvic examination and $45.93 for a Pap smear collection, according to ACP. “These costs may be amplified by expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results, increased medical visits, and costs of keeping or obtaining health insurance,” the researchers concluded.—Eileen Koutnik-Fotopoulos