CLINICAL UPDATE

Many Pelvic Exams Are Medically Unjustified

By Jamie Habib | January 2, 2013

Nearly all obstetrician-gynecologists consider the bimanual pelvic examination a very important part of the well-woman checkup, and sometimes perform the examination unnecessarily in asymptomatic women, according to the results of a nationwide survey of 521 gynecologists and obstetrician-gynecologists in the United States.¹

The pelvic examination—manual inspection of the cervix and uterus in conjunction with a Papanicolaou (Pap) test—has been the center of annual well-woman examinations, which allow for an evaluation of a patient’s overall health and for the early identification of any budding health problems. To better understand why clinicians perform the examination, surveyed physicians were asked whether they would perform a bimanual pelvic examination in a series of vignettes involving asymptomatic patients aged 18, 35, 55, and 70 years who did not need a Pap test.

According to the study findings, nearly all of the physicians would perform routinely a bimanual pelvic examination in asymptomatic, low-risk women. Most physicians would perform the examination on a 55-year-old woman with no ovaries, uterus, or cervix, with more than half of surveyed physicians citing a bimanual examination to be “very important” in this scenario. In addition, 47% of physicians reported using pelvic examinations as a means to screen for ovarian cancer despite that this examination is not recommended for this purpose.¹ Other reasons given for performing the bimanual pelvic examination were adherence to standard medical practices (45%), patient reassurance (49%), and identification of benign conditions of the uterus (59%) and the ovaries (54%).

The updated guidelines for preventive care by the American Congress of Obstetricians and Gynecologists (ACOG), the US Preventive Services Task Force, and the American Cancer Society state that annual Pap tests are not needed for most women. ACOG also has recommended that the bimanual examination should not be part of a routine well-woman examination until age 21.²Despite these recommendations, about 87% of the physicians surveyed said they would perform this examination on 18-year-old healthy women. Physicians also said they perform the examination to reassure patients, to meet patient expectations, and to ensure “adequate compensation for routine gynecological care.”^1,2

Of concern is that these examinations could result in unnecessary surgeries or women being falsely reassured, said Jillian Henderson, PhD, MPH, lead author of the study.² “We need to have more discussion over whether the benefits of these exams outweigh the harms, and if they should be part of a woman’s annual checkup.”

Pertinent Points:
- Many pelvic examinations are performed unnecessarily, the results of which could result in unnecessary procedures or false reassurance.
- Many pelvic examinations are mistakenly performed to screen for ovarian cancer.

by Devdas Acharya | January 18, 2013 8:02 AM EST

In the Indian setting, being a rather conservative population, there is a cultural induced hesitation on the part of the clinician in the pelvic exam of particularly the young unmarried woman , even if she reports symptoms . It is perhaps advisable to do it depending upon the clinical situation.

by Kyoko Nakauchi | January 16, 2013 9:55 PM EST

As Doctor Sundari Nandyala pointed out, we are pretty much the same in Japan.
We do NOT perform routine PE, Pap Smears or any kind of invasive procedure on our patients just because.
Even less on asymptomatic women, teens or virgins which seems to be the atrocious "preventive screening" culture in the United States and Canada. How can they brainwash women and girls into thinking the MUST go to the Gynecologist and have such invasive examinations without having any real symptoms is beyond me. Once a year?
You should NEVER try to examine a teen or a virgin with an speculum when there is NO serious justification in the first place. Young women tend to have abnormal cells and give out way more false positives than older women.
But then again, the more women you test the more cash incentives you receive if you work in the U.S. I heard. Must be really worth it?

by Nicki Smith | January 16, 2013 9:00 PM EST

Based on some of your comments, it is painfully obvious that some of you have forgotten that the decision for whether or not to have a chaperone present is legally the patient's, not yours. You cannot "always"have a chaperone in attendance and it is extremely presumptuous to suggest it. Regardless of the gender of the doctor or nurse practitioner performing the exam, if the patient does not want a chaperone present, you cannot legally have one in the room. That is the law. Those of you who were recommending that a chaperone "always" be present instead of that the patient be asked if she wants a chaperone, as is her legal right, would be advised to brush up on it.

by curtis cates | January 16, 2013 6:43 AM EST

as with any medical testing, the sensitivity and specificity of a bimanual pelvic exam is what's at issue here...
and it's my experience that there are too many variables in terms of physician competence as well as patient habitus and condition to allow for any sweeping generalizations...

in terms of sensitivity...using it as a screening test at least once, is certainly reasonable...as long as we're talking about a sexually active patient...
otherwise it becomes like NTSB screening at the airport...

as far as specificity goes, this is where physician competence and experience tends to make it a very relative, albeit inexpensive, option.

In my opinion, bimanual pelvic examination as a skill seems likely to be eventually replaced by intravaginal US...at least because of technology's more generally predictable sensitivity and specificity...

by sundari nandyala | January 14, 2013 6:01 AM EST

In India scenario is different. we do not perform routine pelvic examination in young women unless they come with complaints.Pap smear is not done annually here.

Article Comment Pages: 1 2 3 Next

1. Henderson JT, Harper CC, Gutin S, et al. Routine bimanual pelvic examinations: practices and beliefs of US obstetrician-gynecologists. Am J Obstet Gynecol. 2012 Nov 22. [Epub ahead of print.]
2. Study questions reasons for routine pelvic exams. Available at: http://www.eurekalert.org/pub_releases/2012-12/uoc--sqr121412.php. Accessed December 17, 2012.