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"I worry that women will conclude that there is no value to an annual well-woman visit," says author Paula Hillard, MD.
New ACP guidelines on pelvic examination draw controversy
A Clinical Guideline from the American College of Physicians (ACP) is calling into question the need to perform screening pelvic examination in asymptomatic, nonpregnant, adult women. In response to the recommendation, based on a systematic review of literature spanning more than 60 years, the American College of Obstetricians & Gynecologists (ACOG) issued a practice advisory in support of its 2014 Committee Opinion on the Well-Woman Visit, suggesting that the annual visit has value and that health care provider and patient should share in the decision about whether to do a pelvic examination.
Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians was published in Annals of Internal Medicine. The ACOG Practice Advisory on Annual Pelvic Examination Recommendations appears on the College’s website.
The guideline represents analysis of published literature on pelvic examination in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. “Pelvic examination” was defined as speculum and bimanual examination; Pap smear for cervical cancer screening was not included. Outcomes assessed included morbidity, mortality, and harms such as overdiagnosis, overtreatment, diagnostic procedure-related harms, fear, anxiety, embarrassment, pain, and discomfort. The evidence and recommendations were graded using the ACP’s clinical practice guidelines grading system.
The ACP analysis found that pelvic examination has little diagnostic accuracy for detection of ovarian cancer or bacterial vaginosis. No studies were found that addressed the diagnostic accuracy of pelvic examination for asymptomatic pelvic inflammatory disease, gynecologic cancer other than cervical or ovarian cancer, or benign conditions. Fourteen low-quality studies of potential harms such as fear, anxiety, embarrassment, pain and comfort, were included in the analysis.
Overall, the ACP found that “the current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination.” Calling the procedure “low-value care,” the ACP report concluded that “screening pelvic examination exposes women to unnecessary and avoidable harms with no benefit (reduced mortality or morbidity rates). In addition, these examinations add unnecessary costs to the health care system ($2.6 billion in the United States).”
ACOG, in its Practice Advisory, acknowledged that “no current scientific evidence supports or refutes an annual pelvic exam for an asymptomatic, low-risk patient,” but that “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.”
By Paula J. Adams Hillard, MD
The recent clinical guidelines from the American College of Physicians (ACP) focus on the currently available evidence regarding the efficacy of pelvic exams for screening in asymptomatic adult women. The conclusion is that “the current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination.”1
While I cannot disagree with the statement about the current evidence, I am afraid that the conclusions that may be drawn from this statement and the consequences that will result will ultimately harm women, and thus I am concerned and distressed. From this statement, I worry that women will conclude that there is no value to an annual well-woman visit.
As noted in the ACOG Committee Opinion on the Well Woman Visit, the annual well-woman visit is an opportunity to further the relationship that a woman has with a trusted clinician, who is able to assess, screen, evaluate, counsel, and provide health and preventive guidance.2 The visit typically includes a determination of vital signs-screening for hypertension and overweight/obesity. The “vital sign” of a menstrual history is also important as a measure of overall health, particularly among adolescents.3 At well woman visits, I regularly screen by medical and social history (talking with my patients and listening to their concerns) for health risks, including the risk of an unintended pregnancy, risk for sexually transmitted infections, and domestic violence. I perform a physical exam, when indicated-by age, risk factors, elicited symptoms, and family history. I agree with the ACOG Committee Opinion that the components of the examination may vary, depending on these factors.
I am reminded of the US Preventive Services Task Force’s (USPSTF) 1996 conclusions on screening for domestic violence, which said that there was “insufficient evidence to recommend for or against the use of specific instruments to detect domestic violence.”4 Those of us who have been routinely screening for many years were disappointed with these conclusions, but subsequently, more evidence emerged from well-performed studies, and the criteria and process for balancing benefits and harms was revised. The current recommendations state that “the USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services.”5 The evidence thus supports a key component of the annual well-woman examination. We will see what the future brings in terms of the evidence for performing the pelvic examination on “asymptomatic” women.
Many women put their own health last, prioritizing the health of their family members (children, spouse, parents) above their own. Thus, without strong support for an annual preventive care visit, they may not seek medical care for themselves. In addition, “symptoms” are subjective-and easy to ignore. We once talked about ovarian cancer as having no symptoms. When assessed more carefully, we’ve learned that subjective symptoms of pelvic pain, bloating, and abdominal fullness when taken together, should not be ignored, as they are present more frequently among women with ovarian cancer than among healthy women.6
Finally, how do I assess, in a carefully performed study, the value of reassurance when an examination is normal? Every day in my clinical practice, I see women who hesitantly share with me their fears and concerns; some of these women have medical conditions that require evaluation and treatment. Many of them would not have “complained” or noted symptoms to bring them to me for an “indicated” examination, but when they are met with a sympathetic actively listening clinician at their annual well-woman visit, they hesitantly express the concerns and fears that prompt an assessment that often includes an examination. After an examination, I am able to reassure many of these women that their examinations are normal. But in my 30+ years of clinical experience, I would tell you about those annual examinations where I have found thyroid nodules, breast cancers, enlarged livers, worrisome adenopathy, vulvar cancers, vulvar and vaginal and cervical lesions, vulvar lichen sclerosus, anal cancers, uterine cancers, ovarian masses, and more.
Until women have the knowledge and feel empowered to understand their bodies (including their “private” parts); until our health care system is more rational and provides universal coverage for women’s reproductive needs; until women’s “complaints” are not discounted or dismissed and until women’s voices are given appropriate credence, I will continue to support annual well-woman visits, with pelvic examinations as appropriately indicated-both for screening of “asymptomatic” conditions, and for evaluation of symptoms that may not be the expressed “chief complaint.”
Dr. Hillard is Professor, Department of Obstetrics and Gynecology, Chief, Division of Gynecologic Specialties, Stanford University School of Medicine, and a member of the Contemporary OB/GYN Editorial Board.
1. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, Clinical Guidelines Committee of the American College of P. Screening pelvic examination in adult women: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2014;161(1):67-72.
2. Committee on Gynecologic Practice. Committee opinion No. 534: well-woman visit. Obstet Gynecol. 2012;120(2 Pt 1):421-424.
3. ACOG Commitee on Adolescent Health Care. Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. ACOG Committee Opinion 349. Obstet Gynecol. 2006;108(5).
4. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Washington, DC: Office of Disease Prevention and Health Promotion;1996.
5. Moyer VA. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013;158(6):478-486.
6. Goff BA. Ovarian cancer: screening and early detection. Obstet Gynecol Clinics North Am. 2012;39(2):183-194.