By Amy Romano
Pelvic exams have historically been a routine part of healthcare for millions of women and as a midwife I have performed hundreds throughout my career. But a new recommendation may change this practice moving forward.
In late June, the U.S. Preventive Services Task Force concluded that pelvic exams have no proven benefits for healthy women. After reviewing decades of research, the task force determined that routine pelvic exams rarely detect hidden diseases and do not reduce death rates. The conclusion applies only to women who are not pregnant and who do not have potentially problematic symptoms like pain or heavy bleeding.
And the conclusion refers only to pelvic exams, which involve using a speculum to examine the vagina and cervix, and a bimanual examination of the uterus, fallopian tubes, ovaries, and bladder. Women still need to get Pap tests, which screen for cervical cancer (though for many women the tests can be done infrequently), and may need to be tested for sexuality transmitted diseases.
Given that more than 60 million pelvic exams are performed each year, it’s important to understand the recommendation and to talk about what it means to women and to providers. Routine screenings like pelvic exams should be supported by evidence that they actually benefit women’s health. In this case, there is little data to show that they do.
Despite this lack of evidence, health care providers continue to perform pelvic exams, possibly more out of ritual than evidence-based practice, notes Dr. George Sawaya, a professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.
It’s not just that the exams have questionable value in keeping women healthy. They can also cause harm to women:
For instance, when a pelvic exam “detects” ovarian cancer, the chance that the woman actually has that often-fatal disease is 0 percent to 3.6 percent. But a woman given that frightening news, or the less dire news that she has a less serious condition such as ovarian cysts or fibroids, will typically undergo additional, sometimes risky, tests, including biopsies and even surgery for something that might never have affected her.
And even if the exam does find endometriosis, ovarian cysts, or pelvic inflammatory disease, for example, the research does not show that detecting these conditions before a woman is symptomatic is better for women than waiting for symptoms to appear. Especially when we don’t have treatment to prevent the symptoms from occurring or the disease from progressing.
In seven years of performing pelvic exams on healthy, asymptomatic women, I have never once discovered a chance finding that turned out to be a disease. I have had false positives that required further testing. False positives and false negatives are both associated with routine pelvic examination.
The American College of Physicians (ACP), an organization representing internists, released similar recommendations in 2014 against routine pelvic examinations. The group’s analysis of published literature on human subjects from 1946 through January 2014 showed that the harms of regular pelvic exams outweigh any potential benefits.
The American College of Obstetricians and Gynecologists (ACOG) still recommend, based on “expert opinion” (not evidence), yearly pelvic exams for women 21 years of age and older.
The ACP and the task force’s findings are useful. But if we are going to prioritize patient-centered care, it’s even more helpful to address how providers can and should use this information to provide optimal care to women. The group released guidelines alongside their recommendations that include advice to help doctors and patients understand the benefits, harms, and costs of the pelvic examination so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.
There is actually quite a bit of evidence that attending to women’s emotional well-being may be more valuable than many of the routine medical tests we put them through.
It’s important that we strive to provide woman-centered and respectful health care for women. To do this, we need to invite women into a conversation about their health and health care. We need to listen to women when they say pelvic exams can be uncomfortable, painful, or even traumatic. It’s up to health care providers to defer the exam in favor of doing something a woman actually needs or wants. If pelvic exams do not fit it into either of those categories, it may be time to ditch them.