Who needs a screening pelvic exam anyway?

The screening pelvic examination, once a staple of a woman's annual health visit, has become embattled with scrutiny in recent years as medical societies published incongruous reviews, recommendations, and guidelines.

On one hand, ACP strongly recommends against performing a routine pelvic examination in asymptomatic, nonpregnant women because such harms as false-positive testing and unnecessary surgery outweigh scant evidence of benefit. Meanwhile, the American Congress of Obstetricians and Gynecologists (ACOG), citing expert opinion, recommends offering annual screening pelvic exams to women ages 21 and older as part of shared decision making.

Most recently, the U.S. Preventive Services Task Force (USPSTF) in March determined that the current evidence was insufficient to recommend for or against periodic screening with the pelvic exam. In effect, “I think it added a big dose of uncertainty about what the clinical action should be,” said George F. Sawaya, MD, a professor of obstetrics, gynecology, and reproductive sciences and epidemiology and biostatistics at the University of California, San Francisco.

A recent randomized controlled trial conducted by Dr. Sawaya and his research group tested the effect of receiving the ACP versus ACOG recommendations on women's desire for a routine pelvic examination. Results were published online in May by the American Journal of Obstetrics & Gynecology.

ACP Internist recently spoke with Dr. Sawaya about the results of his study and how internists should handle conflicting screening pelvic exam recommendations in practice.

Q: Are there similarities among the three groups' opinions?

A: What is common across all three recommendations is that they all acknowledge that there is no evidence of benefit, at least for anything we have measured. Now, ACOG might say we haven't measured the right things, and maybe the Task Force would say that as well. But I think what is most puzzling is that neither of these groups have been able to articulate what the possible benefits might be.

Q: How should internists navigate the conflicting guidelines that are out there?

A: For an individual clinician, I think they should make patients aware of the uncertainty among these three professional groups and that one group, the ACP, believes the harms outweigh the benefits. Then the patient can at least be aware that there's controversy. She might opt out of the exam, or she might say, “Well, this is something I feel comfortable with. I've always felt like this was valuable for me, and I would rather just continue it,” fully aware that there are potential harms and no evidence of benefits. Studies have shown that there's a feeling of reassurance that women get from this exam. That's not ignorable.

Q: You tested the effect of informing women about the recommendations on their decision to opt in or out of the screening pelvic exam. What did you find?

A: We found that about 80% of women who got the ACOG recommendations in favor of the exam wanted to have it. Among women who got the ACP recommendation stating that the harms outweigh the benefits, only about 40% of them wanted the exam. The difference between 80% and 40% is pretty substantial for an educational intervention that takes just a few minutes. What is even more fascinating, though, is that 40% of women who were told that the harms outweighed the benefits still wanted the exam.

Q: So if a woman decides she wants the exam but her internist doesn't believe it's indicated, how should the physician proceed?

A: I think preserving the physician-patient relationship is extremely important. The physician needs to explain the reasoning behind the recommendations and fully disclose what might happen: “I may find a fullness or an abnormality that will prompt you to get an ultrasound, and that may lead to other ultrasounds or it may be entirely normal, or we may go down the road where it's a persistent abnormality that requires surgery. Most surgeries are for lesions that are not clinically important. But as long as you're aware of that, then I think we can do the exam.”

Now, it can cause a bit of a conflict because you might have a physician who feels like the examination is contraindicated, right? That physician might refer the patient to another physician. You're at least empowering the patient to make the decision.

Q: When is a pelvic exam indicated?

A: It's really important that people know that there are indications for pelvic exams. For example, if the patient has abnormal bleeding or discharge, she certainly may need a pelvic examination. It is important to remember that there are indications for speculum exams in asymptomatic women that the Task Force endorses, such as for cervical cancer screening and screening for certain sexually transmissible infections (STIs). I think people have to be clear that in this conversation, we're not talking about cervical cancer screening or screening for STIs, and we're not talking about symptomatic women. We are talking about the pelvic exam as a standalone test in the absence of any other indication to perform it.

Q: What is the appeal, then, of the screening pelvic exam?

A: I've been lecturing about this for about 12 years now, and I used to end all my talks with, “There are two not-very-good reasons to do the exam that, maybe together, perhaps make an OK reason.” The first is that patients expect the exam as part of the visit to the gynecologist. The second involves training. It has been argued that we need to know what normal is so that when we see abnormal, we'll know what abnormal is. These two reasons seem to have some validity; I just don't know whether or not they are strong enough to expose women to harm.

Q: What might primary care's well-women exam look like in the future?

A: ACOG and the USPSTF have been very good about delineating what should be included in the periodic well-woman exam. (That doesn't necessarily mean an annual exam, but a periodic exam for asymptomatic women.) There are a lot of things on the list, aside from cervical cancer screening and STI screening. There are important interventions that don't involve taking a sample, such as depression screening, counseling for smoking cessation, etc. I hope in the future there will be more attention focused on things that are important to patients [and] involve more talking and listening rather than sampling. Over time, we will get more thoughtful about what it means to deliver patient-centered care.