USPTF Rebuttal: Why Women Still Need Pelvic Exams

Recently, the U.S. Preventive Services Task Force (USPSTF) concluded that there is limited evidence to support doing routine pelvic exams for women who are healthy and not pregnant. They say: “There is limited evidence regarding the diagnostic accuracy and harms of the routine screening pelvic examination to guide practice.”

An Absence of Evidence
Does this lack of evidence mean there is no benefit to routine pelvic exams? Absolutely not. The absence of evidence does not indicate the evidence of absence. In other words, if there is absence of or limited evidence for the benefits of routine pelvic exams that does NOT mean there is adequate evidence to recommend against them. In fact, these most recent draft guidelines don’t make much sense to me at all. Here are just a few reasons why:

• Possibility of bias- The authors are all women from the West Coast of the US, and there isn’t a single gynecologist among them, so there is a significant absence of diversity (by gender, by geography, and by specialty) which could be a source of bias. In fact, most of the authors are not physicians, nor have they ever performed a routine pelvic exam.

• “Insufficient” evidence- The authors note that “the current evidence is ‘insufficient’ to determine the balance of benefits and harms of the pelvic exam,” however, this didn’t deter them in drafting recommendations in favor of stopping routine pelvic exams.

• The authors judged the effectiveness of the pelvic examination in reducing all-cause mortality, cancer- and disease-specific morbidity and mortality, and improving quality of life. These are all very “blunt instruments” (aka insensitive assessments) which are particularly obtuse in younger women where death and cancer related morbidity are rarely relevant, and almost never proximate in time.

• The authors found only eight studies looking at the diagnostic accuracy of pelvic exams, and for only four medical conditions: ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes. So in the studies evaluated, the only endpoint that would lead to mortality, cancer- and disease-specific morbidity and mortality, is ovarian cancer, and everyone knows that the pelvic exam is notoriously bad for detecting ovarian cancer. Furthermore, no one dies from bacterial vaginosis, genital herpes and vaginal trichomoniasis, all of which are treatable (and don’t cause death).

• Finally, the authors did not recommend changes to current cervical cancer screening guidelines (aka pap smears with or without human papilloma virus (HPV) testing). Since these guidelines DO recommend routine cervical cancer screening, which does require–at a minimum–a vaginal speculum exam (not exactly the same as a pelvic exam), how is one to do this without a routine screening pelvic examination?

So, at the risk of being redundant, I strongly disagree with the conclusion of the USPSTF draft evidence review, but particularly as it applies to postmenopausal women. There is a lot more that goes into the routine gynecological visit, including the pelvic exam. The pelvic exam is needed to screen for conditions such as the genitourinary syndrome of menopause (vaginal atrophy, that affects more than 50% of postmenopausal women), fibroid tumors, abnormal or heavy menstrual bleeding, pelvic floor conditions, and cancers and precancers of the vulva, vagina, cervix and uterus, etc. Not to mention: gonorrhea, chlamydia, syphilis, hepatitis, HIV; spousal, alcohol and drug abuse; menopausal hot flashes and night sweats, sexual dysfunction, among many other conditions.

Missed Opportunities
Broadly, the conclusion to discontinue the routine pelvic exam runs counter to the goals of improving women’s health through preventive care. If pelvic exams are performed only when women complain of problems or have symptoms, we will miss opportunities to diagnose potentially fatal pelvic cancers and other conditions. Being asymptomatic is not the same as being healthy or not having a problem.
Sincerely,

Dr. James A. Simon, MD, CCD, NCMP, IF, FACOG