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Wednesday, February 16, 2011

Questioning the Need For Routine Pelvic Exam

Questioning the Need For Routine Pelvic Exam

Commentary Argues It Deters Regular Gynecological Care

Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.
Many women find it embarrassing, invasive and even painful. And being instructed to "relax" frequently has the opposite effect.
Now, a commentary in the January Journal of Women's Health has raised a provocative argument: For healthy women with no symptoms of disease, a routine pelvic exam serves little purpose—and may be so disliked that it dissuades some women from getting regular gynecological care.
"If a woman is asymptomatic and feeling fine, getting naked on a table with stirrups and a speculum is not adding extra value," says lead author Carolyn Westhoff, a professor of Obstetrics and Gynecology at Columbia University Medical Center and of epidemiology at the Mailman School of Public Health. "We should be talking about diet and exercise and immunizations—and having time to listen to what she's worried about. We can let go of something that is uncomfortable and embarrassing and not that useful."
In fact, the American College of Obstetricians and Gynecologists (ACOG) is re-evaluating its recommendations on the subject. "We are looking at this very closely," says Cheryl Iglesia, chair of ACOG's Committee on Gynecologic Practice.
Traditionally, a key reason for doing a pelvic exam has been to take a Pap smear—a sample of cells on the cervix to check for signs of cervical cancer—long recommended annually. But in late 2009, ACOG revised its recommendations for Pap smears to every two years for women ages 21 and 30 with no symptoms or other risk factors, and every three years from 30 and older.
Given that change, ACOG is rethinking other elements of the annual exam as well, says Dr. Iglesia. "There may be times when [a pelvic exam] is not necessary and your 15 minutes of managed-care time may be better spent talking."
In addition to the Pap smear, an ob-gyn also traditionally uses a pelvic exam to check the ovaries and uterus for signs of cancer. The ob-gyn uses two fingers to palpitate the organs inside while pressing on the patient's abdomen from the outside, the so-called bimanual exam.
But Dr. Westhoff and her co-authors point out that bimanual exams don't lead to earlier diagnoses of ovarian cancer and aren't recommended for that purpose by ACOG, the American Cancer Society or the U.S. Preventative Service Task Force. They are seldom performed in the United Kingdom, where the proportion of women diagnosed with Stage 1 ovarian cancers is the same as in the U.S.
Bimanual exams do sometimes lead to additional tests and procedures, such as having ovarian cysts or fibroids removed that may have resolved on their own, says Dr. Westhoff, who notes that one reason ACOG moved away from annual Pap smears was that abnormalities seen there sometimes led to laser excisions or biopsies that could harm a patient's fertility unnecessarily. When women do have symptoms, such as abdominal pain, backache or irregular bleeding, ultrasounds can reveal more information than palpitation can, she adds.
Pelvic exams are also commonly used to screen for sexually transmitted diseases and before prescribing contraceptives. But the authors note that chlamydia and gonorrhea can be detected just as well via blood or urine tests or with swabs that women can administer themselves. And while a pelvic exam is needed to fit a diaphragm or insert an intrauterine device for birth control, there's no need for one before prescribing the pill or a patch.
"I don't want a young woman to be afraid to come in for contraception because she's afraid she'll get a pelvic exam," says Dr. Westhoff. "The pelvic exam is irrelevant to starting the pill. But a substantial portion of doctors still require one. I think a lot of them have just been taught that that's the thorough way to take care of patients, and nobody has stopped to ask, 'What are you looking for?' "
Some other ob/gyns say a pelvic exam can provide numerous clues to a patient's condition. "There's a treasure trove of information you can glean from a pelvic exam," says Laurie Green, a San Francisco ob/gyn.
For one thing, Dr. Green says she can gauge roughly how close a woman is to menopause from the color of her vaginal walls, and says she has occasionally spotted malignant melanomas. She has also spotted cancers during the rectal portion of the exam, and cervical polyps that can make intercourse painful.
Bimanual exams can sometimes detect early stages of endometriosis, an overgrowth of uterine lining outside the uterus, and fibroids that may be asymptomatic now but can pose problems later. "I've had patients who get pregnant and they come in with massive fibroids, and if the fibroids had been removed earlier, they would have a much lower risk for preterm labor," says Dr. Green. "You would lose all of that if you didn't do a pelvic exam."
And while many women detest the pelvic exam, some consider it a crucial part of the visit. Mary Jane Minkin, a professor of ob/gyn at Yale University School of Medicine, says that with the older women she sees in her private practice, "I'm discussing their general health, health habits, weight, exercise regimens, smoking, sexual issues—all of it important—but what sanctifies the visit is the pelvic exam."
Without it, she wonders, "Would they really come in regularly for the health counseling and would insurance reimburse for it?"
Another issue is litigation, Dr. Minkin says. "If something could have been picked up on a pelvic exam and a pelvic wasn't done, do we get sued?"
Dr. Minkin also cautions that while women in monogamous relationships aren't at high risk for cervical cancer, some women only think their relationship is monogamous, so an annual check provides additional protection.
Whether it's done every year or less frequently, a pelvic exam is still necessary periodically, and some doctors, at least, are focusing on ways to make it less uncomfortable for patients.
Robert Reid, a professor of ob/gyn at Queens University in Kingston, Ontario, has developed a video giving medical students more guidance on how to give a "compassionate" pelvic exam. The tips include warming the speculum and testing it on a patient's skin first as well as explaining every step so there are no surprises.
"This is from over 30 years of watching novices make mistakes," he says. The video has been adopted by Canada's Association of Professors of Obstetrics and Gynecology, which distributes it to all Canadian medical schools, and it will be demonstrated at a conference of U.S. ob/gyn professors in San Antonio next month.

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