Despite Recent Report, You Still Need an Annual Pelvic Exam
Recently, the U.S. Preventive Services Task Force (USPSTF) concluded that, “the current evidence is ‘insufficient’ to determine the balance of benefits and harms of the pelvic exam.” The USPSTF then made the recommendation to discontinue routine pelvic exams for women who are healthy and not pregnant. The broader media jumped on this as if it were fact, and an accepted change in practice. But 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- If there is an absence of or limited evidence for the benefits of routine pelvic exams that does NOT mean there is adequate evidence to recommend against them.
The conclusion to discontinue the routine pelvic exam runs counter to the goals of improving women’s health through preventive care- Being asymptomatic is not the same as being healthy or not having a problem. The recommendation to perform pelvic exams only if women complain of problems will lead to missed opportunities to diagnose potentially fatal pelvic conditions. I understand that women do not like pelvic exams as they are intrusive, invasive and sometimes painful, but here is a fact I think most people are forgetting: they save lives. If you never check a temperature you’ll never find a fever.
Many others are also refuting the elimination of routine pelvic exams. As Dr. Maureen Phipps told the New York Times, “This is not a recommendation against doing the exam. This is a recommendation to call for more research to figure out the benefits and harms associated with screening pelvic exams. That’s the big message here.” She is the chairwoman of obstetrics and gynecology at Brown University’s Warren Alpert Medical School and was on the USPSTF task force. The American College of Obstetrics and Gynecology (ACOG) and other organizations are still recommending yearly pelvic exams for women over the age of 21.
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. Women 18 years and older or anyone with risk factors like multiple partners, history of HPV, chronic infection or fertility issues should be seeking routine pelvic exams and pap smears. Contact our office to see if you should come in for a screening.
Sincerely,
Dr. James A. Simon, MD, CCD, NCMP, IF, FACOG
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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
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Released July 1, 2016
Under the editorship of NAMS Executive Director JoAnn V. Pinkerton MD, NCMP, First to Know presents commentary on the latest, breaking scientific articles as suggested by members of The North American Menopause Society (NAMS), the leading nonprofit scientific organization dedicated to improving women’s health and quality of life through an understanding of menopause and healthy aging. Opinions expressed in the commentary are not necessarily endorsed by NAMS or by Dr. Pinkerton.
USPSTF looks for public comment on routine pelvic exams draft evidence review
“There is limited evidence regarding the diagnostic accuracy and harms of the routine screening pelvic examination to guide practice.”
Guirguis-Blake JM, Henderson JT, Perdue LA, Whitlock EP. Screening for Gynecologic Conditions With Pelvic Examination: A Systematic Review for the US Preventive Services Task Force. Evidence Synthesis
No. 147. AHRQ Publication No. 15-05220-EF-1. June 2016.
Summary. The US Preventive Services Task Force (USPSTF) has opened for public comment a draft evidence review on the necessity of annual well-woman pelvic examinations. The final evidence review will be used to inform the first-ever USPSTF recom- mendation statement on pelvic exams.
The USPSTF has pointed out that although some 60 million pelvic exams are done each year, the practice has not been very well studied and said that the current evidence is “insufficient” to determine the balance of benefits and harms of the pelvic exam.
The systematic review was written to support the USPSTF in creating its recommendation on the periodic screening pelvic examination. The authors sought to discover direct evidence for the effectiveness of the pelvic examination in reducing all-cause mortality, cancer- and disease-specific morbidity and mortality, and improving quality of life.
The authors performed a search of the medical literature published over the past 60 years. They located just eight studies looking at the diagnostic accuracy of pelvic exams for only four medical conditions: ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes.
In the four ovarian cancer screening studies, with more than 26,000 women screened, more than 96% of the positive test results were false positives, and many patients had unnecessary follow-up procedures. Surgery rates resulting from an abnormal pelvic examination ranged from 5% to 36% at 1 year, with the largest study reporting an 11% surgery rate and 1% complication rate within 1 year.
In the end, the authors found no studies that assessed how effective the exams are for reducing death and disease or improving quality of life.
The draft recommendation does not apply to women who are pregnant or those with existing conditions that need to be evaluated and does not recommend changes to current guidelines for cervical cancer screening.
The American College of Obstetricians and Gynecologists (ACOG) said in a June 28, 2016, statement on the draft recommendations that it continues to recommend an annual pelvic examination for women aged 21 years and older but acknowledges that there is a lack of data. Its Well-Woman Task Force in 2015 recommended annual external exams but said that internal speculum and bimanual exams for women without specific complaints or symptoms should be “a shared, informed decision between the patient and provider.” ACOG is reviewing the draft recommendation to decide whether it needs to update its own pelvic-exam guidelines.
The opportunity for public comment on the draft review evidence expires on July 25, 2016, at 8:00 PM EST. To comment, go to USPSTF draft evidence review.
Commentary. The Executive Committee of The North American Menopause Society (NAMS) strongly disagrees with the conclusion of the USPSTF draft evidence review, particularly as it applies to postmenopausal women. The only four outcome measures available for inclusion in the review—ovarian cancer (for which there is NO good method of detection), bacterial vaginosis, genital herpes and vaginal trichomoniasis—represent a narrow fraction of the key medical conditions screened during the pelvic exam and disregards the many
benefits of the pelvic exam. Although it is perhaps reasonable to recommend against the pelvic exam for diagnosing those four conditions, there is no scientific basis for extrapolating beyond those four specific conditions to the myriad conditions that affect women.
The pelvic exam is needed to screen for conditions such as the genitourinary syndrome of menopause that affects more than 50% of postmenopausal women, neoplasias, fibroids, pelvic floor conditions, and dermatologic conditions associated with elevated disease risks (eg, lichen sclerosis). Broadly, the conclusion to discontinue the exam runs counter to the goals of improving women’s health through preventive care. The recommendation to perform pelvic exams only if women complain of problems will lead to missed opportunities to diagnose pelvic issues. Being asymptomatic is not the same as being healthy or not having a problem. The recommendation to discontinue routine pelvic exams runs the risk of further marginalizing postmenopausal women.
We strongly encourage a call to action to comment on this draft recommendation and to have your voices heard BEFORE women lose their right to routine screening pelvic exams.
The NAMS 2016 Executive Board
JoAnn V. Pinkerton, MD, NCMP, NAMS Executive Director
Peter F. Schnatz, DO, NCMP, NAMS President
Marla Shapiro, MD, NCMP, NAMS President-elect
Pauline M. Maki, PhD, NAMS Past-President
James Liu, MD, NCMP, NAMS Treasurer
Gloria Richard-Davis, MD, FACOG, NAMS Secretary
Sheryl Kingsberg, PhD, NAMS Board Member
