The Routine Pelvic Exam Debate

Contents

1. Three things the word gets confused with
2. How the national bodies split
3. How a review reaches insufficient

Routine gynecological examinations run through the experience Candace Cooley built across her career, and in the 2010s one familiar part of them, the yearly pelvic exam in a woman with no symptoms, became the subject of an open disagreement among national medical bodies. Much of the confusion began with the phrase itself. In ordinary speech the pelvic exam means the whole visit in stirrups, and it is often taken to include the Pap test. For its review, the United States Preventive Services Task Force gave the term a narrower meaning: any of four components, alone or combined, namely a look at the external genitalia, an internal speculum examination, bimanual palpation and a rectovaginal examination.⁷ The Pap test and screening for gonorrhea and chlamydia were set aside, because the task force already had separate recommendations for them.⁷ The debate that followed was about that narrower exam, done as screening, in women who felt well.

Figure

What the term pelvic examination covers

1. 01
   ExternalAssessment of the external genitalia by sight.
2. 02
   SpeculumAn internal examination of the vagina and cervix with a speculum.
3. 03
   BimanualPalpation of the ovaries and uterus between an internal and an external hand.
4. 04
   RectovaginalA combined examination through the rectum and vagina.

Three things the word gets confused with

The first confusion is with the Pap test. A nurse writing in The New Republic in 2014 explained that the Pap test is collected during the middle of the pelvic exam, while the speculum is in place, and is a separate procedure aimed at early cervical changes; headlines that announced the end of the pelvic exam left readers thinking the Pap test had gone too.² The second is with the yearly visit. Reviewing coverage of the 2016 draft, the Association of Health Care Journalists found that few stories made clear that annual well woman care was still recommended whether or not a pelvic exam was done.⁶ The third is with an exam prompted by symptoms. Every position in the debate concerned screening only; for bleeding, pain or other signs of trouble, the exam remained part of the workup.⁵¹ The Pap test has a history of its own, told in a separate entry on cervical screening.

How the national bodies split

The question surfaced in print by 2011. An editorial in MDedge that year summarized a published commentary arguing that the traditional reasons for a yearly exam in women without symptoms were no longer absolute, since some infections could be detected from urine or self collected swabs and the bimanual exam did not appear to improve detection of ovarian cancer.³ The editorial’s author, a gynecologist, defended the exam as a way to find silent vulvar lesions, to notice prolapse that prompts questions about leakage, and to reassure.³

In 2014 the American College of Physicians strongly recommended against annual pelvic exams for healthy, low risk women who were not pregnant, NPR reported, while the American College of Obstetricians and Gynecologists kept its advice of a yearly exam from age 21.⁵ A family physician quoted in the report said that every society, that college included, agreed the exam could not find ovarian cancer in women without symptoms; the obstetricians’ representative argued that the exam could reveal problems women do not raise, such as urinary leakage.⁵ The American Academy of Family Physicians endorsed the internists’ position, as Fox News noted when the task force issued its draft in 2016.⁹

Figure

Where the national bodies stood

	Body	Position on screening exams without symptoms
Internists	American College of Physicians	Recommended against them, judging harms to outweigh benefits
Family physicians	American Academy of Family Physicians	Did not recommend them
Obstetricians and gynecologists	American College of Obstetricians and Gynecologists	Continued to recommend a yearly exam from age 21
Task force	United States Preventive Services Task Force	Found the evidence insufficient to weigh benefits and harms

The task force took a third position. Its draft, described by MDedge, was its first statement on pelvic exams as screening and carried an I grade, meaning the balance of benefits and harms could not be determined.⁴ The obstetricians’ college responded that its own yearly recommendation rested on expert opinion, acknowledged the limits of the internal exam for screening, and promoted shared decision making about whether to perform one.⁴ When the final statement appeared in March 2017, NPR summarized the chair’s view that there was not enough evidence to recommend for or against the exam, and noted that the college planned to review its guidance.¹

How a review reaches insufficient

The final statement, reprinted in American Family Physician, shows how such a verdict is built.⁸ The panel looked first for studies of what matters most: death from any cause, illness or death from specific diseases, and quality of life. It found none that tested screening pelvic exams against those outcomes.⁸ It then looked at accuracy and found limited evidence for only four conditions: ovarian cancer, bacterial vaginosis, genital herpes and trichomoniasis.⁸ For ovarian cancer, positive predictive values ran from 0 to 3.6 percent and false positive rates from 1.2 to 8.6 percent, and between 5 and 36 percent of women with abnormal findings went on to surgery.⁸ No study measured the anxiety the exam might cause.⁸ NPR put the concern in plain terms: an abnormal finding leads to more testing for as many as 8 percent of women examined, and up to a third of those women end up having surgery. The author of an editorial published alongside the final statement, a gynecologist at the University of California, San Francisco, added that most of those operations were for conditions that were not cancer.¹ For prevention, he argued, the standard of evidence has to be high, because the people being screened are well.¹ With benefits unmeasured and harms poorly measured, the panel judged the evidence too thin and too poor to set one against the other.

Figure

What the evidence review found

positive predictive value for ovarian cancer in the studies found

0 to 3.6 percent

false positive rates for ovarian cancer

1.2 to 8.6 percent

of women with abnormal findings who went on to surgery

5 to 36 percent

An I statement is not a recommendation against. The task force asked clinicians to weigh each woman’s risk factors, values and preferences and to decide with her through shared decision making.⁸ It also listed the research that could settle the question, including studies of health outcomes, quantified harms, risk tools to identify women who might benefit, and how the exam affects women’s willingness to seek care.⁸ The statement recorded how entrenched the practice was: 44.2 million pelvic exams in 2012, and a 2009 survey in which 78 percent of clinicians said the exam was useful for gynecologic cancer screening in women without symptoms.⁸

The debate left behind a working vocabulary. Screening means examining a woman who has no symptoms, as opposed to a diagnostic exam prompted by a complaint. The pelvic exam has named components, from the external look to the bimanual and rectovaginal steps, and the Pap test is a separate sample. An I grade means insufficient evidence, not proven harm. Asymptomatic, low risk and not pregnant define who the statements covered. With those terms, the question of whether a given exam is worthwhile becomes one a woman can put directly to her own clinician, and the entry on health literacy looks at why such plain terms matter.