Calling all women: What is your reaction to the new recommendation against pelvic exams for healthy women who are not pregnant and show no signs of disease?
Are you thrilled?
Are you a little confused?
If so, Impatient is here for you. I felt those mixed emotions, too, especially as I began to read more about the American College of Physicians' recommendation, and responses to it.
Below, I'll break down for you the reasons for the recommendation, and what obstetricians and gynecologists are saying. Then, I want to hear about what you'll do, next time you get your annual well-woman exam.
A group of doctors wrote in the Annals of Internal Medicine:
"The current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination."
"Evidence shows that the diagnostic accuracy of pelvic examination for detecting ovarian cancer or bacterial vaginosis is low."
The doctors conclude there's limited evidence suggesting that:
"...screening pelvic examinations may be associated with pain, discomfort, fear, anxiety, or embarrassment in about one third of women and can lead to unnecessary, invasive, and potentially harmful diagnostic procedures."
The official reaction
In a statement, the American College of Obstetricians and Gynecologists said it continues to believe in the clinical value of the pelvic exam. Through such exams, the College says, gynecologists can recognize issues like incontinence and sexual dysfunction, and answer patients' personal and intimate questions.
The College's guidelines:
"...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."
And in an editorial accompanying the report, George Sawaya and Vanessa Jacoby, both OB/GYNs at UCSF, write that the recommendation will be controversial:
"Ending such a prevalent practice with widespread support among women's health providers will be met with formidable challenges."
They question the medical literature review that the recommendation is based on, because it focused primarily on older women, and didn't evaluate what many doctors describe as the most important goal of the exam: detecting noncancerous masses:
"Thus, it is reasonable to disagree with using these findings to recommend a major change in clinical practice for women of all ages attending well-woman visits. Many will ask, 'Have all of the pertinent clinical questions been addressed?"
They conclude that the exam - "has become more of a ritual than an evidence-based practice" - and that the recommendation should spur discussions about its true costs and benefits:
“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.”
Some more thoughts from OBs
I reached out to two OB/GYN doctors at Ronald Reagan UCLA Medical Center.
Dr. Erica Oberman responded:
"I personally don't like guidelines that say we should completely stop doing a specific practice, I wish the guidelines would say something more like, 'hey, here's a thought, but use that clinical judgment and common sense that you have honed over the years and put it to work.'"
She explained that she already provides pelvic exams on a case-by-case basis:
"I don't make a virginal, 19-year-old, looking for birth control pills to control periods undergo a pelvic exam just because she is in my office. I do not make a 71-year-old women with a lifetime of negative pap smears who is completely asymptomatic and uninterested undergo a pelvic exam just because her primary care physician wasn't comfortable doing it."
Dr. Daniel Kahn - who does fewer pelvic exams, since he specializes in high-risk pregnancies – acknowledged that he'd always thought that "the annual pelvic exam is a lot to ask of the patient, though I don’t actually know what it is like to go through one."
Still, he said the exam serves a purpose:
"… many times issues are discovered at the pelvic exam that are troublesome to the patient, but she didn't mention until the exam. Usually surrounding pelvic pain or unusual discharge. Since these can herald more troublesome health problems (not necessarily ovarian cancer) and can change over the course of months, having a regular evaluation seems reasonable."
Dr. Oberman added another benefit:
"It gives us an opportunity to educate women about their bodies and talk about things that maybe they aren't comfortable talking about with anyone else."
The good thing about the recommendation, Oberman said, is that it's sparking public discussion about this dreaded exam:
"Hopefully this conversation will continue into the exam room, because that's where it should be happening, so that physician and their patient can talk about their individual risks and circumstances and come up with a plan that is right for the patient."
Now, back to you
A point of agreement – between people who support and question the new recommendation – is that women and their doctors should talk about whether this procedure is right for them.
So, the next time you're due for your annual exam, what will you do?
Women, what’s your reaction to this new guideline? How will it influence what you undergo during an annual exam? Tell us about it in the comments section below, or e-mail us at Impatient@scpr.org. Your insight could inform future reporting.