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 21.2 Despite 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.
B mode and 3D Ultrasound images of a fetal abdomen (35wks) revealing gallbladder calculi
This case study shows a 26 week gestation with a cystic mass close to the sacrum.
CC is a 31 year old primigravida who was referred for ultrasound at a community hospital due to suspected cardiac anomalies noted on a screening sonogram at her doctor's office. Due to concern about a probable cardiac abnormality an amniocentesis was performed at the local hospital.
Single umbilical artery color doppler, transverse scan of urinary bladder shows single umbilical artery (left), transverse section of umbilical cord showing only two vessels: one vein and one artery (right).
Normal 35 week pregnancy
An approx. 12 week fetus, first ultrasound of this pregnancy.
4D image of 29 weeks pregnancy, multiple anomalies: Clinch hand, omphalocoele, single atrium
Is this lesion a fibroid or adenomyosis? Patient is a young (38n yr. old) married female with a history of dysmenorrhea and polymenorrhoea.
The patient was a 38 year old G4 P3, 20w4d. I was doing an anatomic survey today. While I was looking at a long axis view of the fetal heart with color Doppler, the baby developed hiccups, and with each contraction of the fetal thorax (which was quite obvious) I could see an explosion of blue color representing blood going through the foramen ovale from right to left.
This is a confirmed case of scar ectopic pregnancy. Yesterday, I carried out this exam in an emergency room, without much time to perform an adequate sonogram, the patient did not feel good with “cramps” but no signs of bleeding.
Normal aspect of the ossification centers of the fetal sternum at 33 weeks. Size of the ossification centers decreases in a cranio-caudal sense.
Leiomyoma that has undergone fatty degeneration.
Sagittal image from a transvaginal sonogram in a patient with bleeding after a spontaneous abortion. The endometrium (between cursors) was thick and heterogeneous, measuring 8.5 mm in thickness (Fig1). Color doppler image in same patient shows focal flow (Fig. 2 - arrow) within the heterogeneous endometrium.
Images of "Bulky Uterus"
Cystic spaces in the sub-endometrial myometrium of the fundus.
Complete Invasive Mole
A 29-year-old gravida 10, para 3 (1 term gestation, 1 preterm gestation of twins, 1 stillbirth at 5 months, 2 spontaneous abortions, and 4 elective abortions) presented to the clinic at about 5 weeks’ gestation with abdominal pain and vaginal bleeding. She described the pain as sporadic, mostly on the left side, exacerbated by movement, and resolving with rest, and the bleeding as initially intermittent but then heavier “like a period.”
Implantation in the scar of a previous Cesarean is thought to be the rarest of ectopic pregnancies. With the increasing numbers of Cesareans performed, scar implantation may become more frequent as well. We present an illustrative case.
Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome affects at least 1 in 4500 female births.1 The syndrome consists of vaginal aplasia with other müllerian duct abnormalities. The characteristic feature of MRKH syndrome is congenital absence or underdevelopment of the upper vagina and uterus; it is rarely associated with unilateral renal agenesis, ectopia, or horseshoe kidney.
Endometrial stromal sarcoma (ESS) is a rare malignant tumor of the endometrium, occurring in the age group of 40-50 years.
