Do Healthy Women Need Annual Pelvic Exams?
By Rachel Walden — July 24, 2014
More than 60 million pelvic exams are performed each year, but a new guideline from the American College of Physicians suggests that for most healthy women, they’re not needed.
The guideline is based on a 2013 systematic review conducted by the Evidence-based Synthesis Program (ESP) Center of the Minneapolis VA Medical Center. The review looked at the usefulness of pelvic exams in detecting non-cervical cancer, pelvic inflammatory disease, and benign gynecological conditions and found that for most women there is no evidence to support the practice.
For the purpose of the research, a pelvic exam refers to using a speculum to examine the vagina and cervix, and a bimanual examination of the uterus, fallopian tubes, ovaries and bladder. It does not include obtaining a Pap test for cervical cancer screening (learn more about cervical cancer screening guidelines).
It’s also important to note that the recommendations apply only to “average risk” adult women who are not pregnant and who do not have any symptoms, such as pelvic pain, which might mean there is a problem such as endometriosis, ovarian cysts, other pelvic organ problems, or infection.
The review considered whether the harms of the pelvic exam are outweighed by the benefits, and whether these vary by patient or provider characteristics. Possible harms include fear, anxiety, embarrassment, pain and discomfort, as well as urinary tract infections and symptoms, overdiagnosis, and overtreatment.
There are also potential procedure-related harms. For example, researchers report that heavier women are more likely than women of average weight to report more disrespect and embarrassment during a pelvic exam. Women with a history of exposure to sexual violence are also more likely to report fear, embarrassment and anxiety.
Overall, the review concludes:
There are no data supporting the effectiveness of the screening pelvic examination (including speculum and bimanual examinations) in the asymptomatic average risk woman for any indication other than periodic cervical cancer screening. The procedure causes pain, discomfort, fear, anxiety, and/or embarrassment in about a third of women and can lead to unnecessary, invasive, and potentially harmful diagnostic procedures. Conducting a pelvic examination requires additional clinician time, especially in primary care settings, and often requires the presence of a chaperone in the examination room, thus incurring resource and opportunity costs.
As a result, the new ACP guideline recommends against routine pelvic exams and concludes:
The current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination. Indirect evidence showed that screening pelvic examination does not reduce mortality or morbidity rates in asymptomatic adult women … No studies assessed the benefit of pelvic examination for other gynecologic conditions … Also, there is low-quality evidence that screening pelvic examination leads to harms, including fear, anxiety, embarrassment, pain, and discomfort, and possibly prevents women from receiving medical care.
In an editorial accompanying the ACP guideline, two physicians from University of California, San Francisco urge proponents of the exam to better understand its benefits and potential harms:
The pelvic examination has held a prominent place in women’s health for many decades and has become more of a ritual than an evidence-based practice. Regardless of whether the American College of Physicians’ recommendation changes practice among obstetrician-gynecologists, it should prompt champions of this examination to clarify its goals and quantify its benefits and harms. Even if net benefit is ultimately shown, the question of value will need to be addressed to understand the resources required to achieve that benefit. With the current state of evidence, clinicians who continue to offer the examination should at least be cognizant of the uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow.
The American College of Obstetricians and Gynecologists responded to the recommendation by urging women to continue to see their healthcare providers each year for well-woman visits. These visits can sometimes include a pelvic exam, but are also an opportunity to get medication refills, review your medical history, have age-appropriate screenings and immunizations, and discuss other concerns with your provider.
ACOG also continues to recommend pelvic exams, while acknowledging that they are not evidence-based:
The College’s guidelines, which were detailed in this year’s Committee Opinion on the Well-Woman Visit, acknowledge that no current scientific evidence supports or refutes an annual pelvic exam for an asymptomatic, low-risk patient, instead suggesting that the decision about whether to perform a pelvic examination be a shared decision between health care provider and patient, based on her own individual needs, requests, and preferences.
However, the College continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction. While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients. Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician.
I never considered the harmful effects of pelvic exams on some Women. I receive on every year and it is definitely not something I look forward to. Being that I was diagnosed with type 2 diabetes about 2 years ago, I have physicals and exams a lot more frequent than I used to. As for Women who are in good health, it doesn’t hurt to be checked once a year. A lot can change in a year. The incidence of reproductive cancers in Women are increasing each year and it’s better to be safe than sorry.
Yeah, unfortunately this is a significant reality for many women. Myself included. .. but as time goes on, improvements in medical health care for women are seen.
It’s time for us to improve our understanding and dialogue with the gynaecological professionals.
The exam is very important, but very difficult to get through.
I absolutely believe that it is wrong, especially for virgins, to have to get a pelvic exam. I have had so many bad experiences dealing with my religious beliefs and remaining a virgin until marriage. I have seen the eyes of doctors light up when finding out that I am a 25+ year old virgin and then they try everything to force me into an examination – even refusing to treat my other conditions (such as asthma) until I agree to the exam.
They also feed me the stupid line of “being a virgin is mental, not physical”. If so, why is “broken hymen tissue’ always viewed as a sign of r@pe in children? I am Christian, but we definitely value the hymen as the sign of virginity. The only acceptable “breaking” is a life or death examination (which is very rare), falling (again, rarely damages the hymen), and sports (again, rare damage). They spout fake statistics about that MOST women do not have a hymen by the time that they have s3x… this is not true. MOST women, except about 1% DO HAVE A HYMEN UNTIL THE FIRST s3x…
I wish these doctors were not so jealous of the self-control of the women that were able to save themselves until marriage. Nonetheless, it eludes me that they first exam that they want to do is invasive, and then if the results are questionable, they follow with a non-invasive exam (ultrasound)… Here’s a thought… WHY NOT DO THE NON-INVASIVE EXAM FIRST AND THEN THE INVASIVE EXAM IF THERE IS NO OTHER CHOICE? Again, doctors are no idiots, they just love the fact that they are in the position to take a woman’s virginity and no one can stop them. In other word’s, they value their right to legally r@pe virgins. How sick!!!
I’m a 30+ virgin. I had my hymen surgically removed in a hymenectomy procedure during laproscopic surgery. It was causing me rather severe pain and discomfort in everyday life. Still a virgin. Considering additional surgery to remove more of the hymen as well as the vestibule surrounding the vaginal opening.
While I agree with you in principle about the mentality of som physicians that say “it’s all in your head”.. I’m afraid that I can’t agree with the importance placed upon the hymen. The body should not be causing chronic pain in that anatomy, and the importance society has placed on the hymen has caused me severe harm in seeking out medical treatment, because I am a virgin. However, because I am a virgin, it’s easier to rule out the “usual” and more easily treated medical issues and identify that it is in fact the anatomy itself which is the cause of my medical conditions.
“However, the College [American College of Obstetricians and Gynecologists] continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction.”
Because women are unable to recognize those conditions themselves.
“While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients.”
See Keepingitprivate’s comment above.
“Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician.”
Because women can’t figure out their own anatomy these days, need constant reassuring that they’re normal, and how could you answer questions or have open communication without her opening her legs for an unnecessary examination?
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