Doctors should stop performing routine pelvic exams, a key component of regular physicals for women, an influential US medical group said on Monday.
There is no evidence that such pelvic exams are useful and plenty to suggest the procedure provokes fear, anxiety and pain in many women, the American College of Physicians said in a new practice guideline for doctors.
The college’s guideline was published in the Annals of Internal Medicine and was accompanied by an article reviewing the scientific evidence. The recommendation applies only to routine checkups for healthy women, not to women who visit the doctor’s office with medical complaints or who are pregnant.
“The pelvic exam has become a yearly ritual, but I think it’s something women don’t necessarily look forward to,” said Dr Sandra Adamson Fryhofer, an internist in Atlanta who is a former president of the college. “A lot of women dread it.”
The new recommendation contradicts guidelines from the American College of Obstetricians and Gynecologists, which immediately reiterated its support for yearly pelvic exams.
A pelvic exam consists of three elements: inspection of the external genitalia, examination of the vagina and cervix, and the so-called bimanual examination, in which the physician inserts a gloved finger into a woman’s vagina and, with the other hand, presses down on her abdomen to check the shape and size of her uterus, ovaries and fallopian tubes.
The exam takes up time during an annual physical and often requires the presence of a chaperone in the room, which raises costs.
The American College of Physicians reviewed studies of the procedure and concluded that pelvic exams were not accurate diagnostic screening tests for ovarian cancer. A dozen studies have suggested that many women experience pain or discomfort during the exams, and that they may be particularly traumatic for women who have been sexually assaulted.
The reviewers said they could not even find studies that had assessed whether routine pelvic exams of asymptomatic women could reduce death or disease from ovarian and other cancers, or benefit women with common benign conditions such as pelvic inflammatory disease, fibroids or warts.
Until about a decade ago, physicians routinely performed pelvic exams before prescribing oral contraceptives, and they used the exams to screen women for sexually transmitted infections and obtain cultures for testing. Those practices have largely been abandoned, and urine samples are now used to test for sexually transmitted infections.
In recent years some experts have suggested that pelvic exams are so discomforting that they may deter women from going to the doctor altogether.
Gynecologists agree that pelvic exams are not good tools for screening for ovarian cancer, which is notoriously difficult to diagnose. But, they say, experienced physicians can use pelvic exams to find other problems, such as non-cancerous fibroids, and to identify changes linked to urinary incontinence and sexual dysfunction.
“Not everything we do in life can be studied in a randomised trial powered to find a scientifically valid answer one way or another,” said Dr Barbara S. Levy, vice president for health policy at the obstetricians and gynecologists’ group.
“I’m not sure there’s evidence to support most of what we do on physical exams,” Dr Levy said. “Lack of evidence does not mean lack of value.”
The new guideline comes as more routine procedures are critically evaluated in light of scientific studies, part of a move towards evidence-based medicine. In the past few years, several new sets of guidelines have urged scaling back screening procedures for women in particular.
In 2009, the United States Preventive Services Task Force recommended postponing routine mammograms to detect breast cancer until age 50, provoking wide controversy. Many women have ignored the advice.
More recently, the task force, the American Cancer Society and the obstetricians and gynecologists’ group have recommended that, with some exceptions, women aged 21 to 65 should receive Pap smears every three years instead of yearly.