By Georgia Ragonetti-Zebell, MD
It’s that time of year again, mommas. You knew this day would come. You prepared. You shaved your legs, trimmed the, ahem, hedges, and maybe even painted your toenails. You get dressed in the tiniest of gowns and drape a sheet over your lap. Feet in stirrups, slide down.
A little further. A little more. One more scooch.
And just when you think it can’t get any more embarrassing, hellllllooo speculum!
Why? Why do we women have to go through this every year?
If you’ve been reading headlines this week, you may think you don’t have to. The US Preventive Services Task Force released a review this week stating that there is no evidence for the use of routine annual pelvic exams in women without symptoms. The media grabbed attention with headlines such as “Pelvic Exams May Not Be Needed” and “The days of the dreaded annual pelvic exam for women may be numbered” and “Millions of Women undergo pelvic exams with no benefit.”
But those headlines don’t tell the whole story. Let’s review the report.
Pelvic exams as a screening test are difficult to study. Most screening tests are detecting something specific, like cervical cancer with Pap smears. But screening annual pelvic exams are looking for a variety of conditions- cancers, infections, benign diseases like fibroids and dermatologic conditions. The Task Force planned to examine three key questions.
Question 1: Do routine annual pelvic exams a) help women live longer, b) reduce cancer and cancer deaths, or c) improve women’s lives?
There were no studies that addressed this question. Zero, zip, nada. Ok, not helpful.
Question 2: How good are routine annual pelvic exams in screening for gynecologic cancers and other gynecologic conditions?
This question was divided into four specific diseases- ovarian cancer, bacterial vaginosis, herpes, and trichomonas. These diseases were chosen because these are the only available studies on pelvic exam. Note that many diseases that doctors are looking for on exam are not included at all.
Can routine pelvic exam detect ovarian cancer? Four studies were reviewed, and the largest contained over 20,000 women. In this study, 91 cases of cancer were diagnosed, and 88 (or 96.7%) were missed on pelvic exam. Routine screening pelvic exams are not good at detecting ovarian cancer. Not good at all.
Can routine pelvic exam detect bacterial vaginosis, a common vaginal infection? There were two studies included, but these studies were not on women without symptoms. These studies compared methods of detecting BV, including pelvic exam. They then compared positive exam findings (abnormal vaginal discharge) with positive findings under the microscope. BV was correctly identified the majority of the time. Again, many of these women had symptoms, so this data cannot be applied to routine pelvic exams.
Can routine pelvic exam detect herpes? Only one study was identified that addressed herpes found on pelvic examination. And considering that 22% of patients in the study had symptoms at the time of exam and all of the patients were examined at an STI clinic, we can’t exactly call that routine. When lesions were present, they were correctly identified as herpes 98% of the time. The value of this study is also limited since so many patients had symptoms, and the authors were not able to analyze only those without symptoms.
Can routine pelvic examination detect trichomonas, a sexually transmitted infection? Again, only one study was identified, and like the herpes study, was not on asymptomatic women and women were recruited through an STI clinic. Certain exam findings, like a “strawberry cervix” or increased discharge did result in detection. Maybe helpful?
Question 3: What are the downsides of routine pelvic examination?
Harms were reviewed with each of the above studies. Typically, we are concerned with false positives and false negatives when considering screening exams. A false positive on pelvic exam would mean that an abnormality is found when there is no disease. For bacterial vaginosis and trichomonas, an examiner may note abnormal discharge, but under the microscope, no disease is found. Good news, and the patient really didn’t have any “extra” procedures. But in the case of ovarian cancer, an abnormal exam typically results in an ultrasound, maybe lab work and, of course, extra worry for the patient. Potential harm. But this is difficult to quantify. For example, if an abnormal pelvic exam was found in the ovarian cancer study, 11% of women went on to have surgery. While the study endpoint was ovarian cancer (which most women did not have), benign diseases such as dermoid cysts and fibroids were often found during these cases. Are those really false positives?
Another consideration is false negatives. When a woman gets the “all normal” pelvic exam from her doctor, she thinks she is good to go. But that’s not always true as we saw with the ovarian cancer study-doctors missed ovarian cancer 96.7% of the time, when it was there, which is very rare. (Side note-ultrasounds and lab work ALSO miss ovarian cancer that often – we just don’t have a good screening test for it yet.)
Probably the biggest “harm” is the discomfort of the exam itself. Women report anxiety, pain and embarrassment when asked about their feelings on pelvic exam. Negative feelings are higher in women with a history of sexual abuse, chronic pelvic pain and obesity.
It seems clear from the available evidence that routine pelvic exams have no proven benefit. That’s true. But available evidence is, well, pretty much non-existent. It really just hasn’t been studied at all. So why do many gynecologists (and ACOG) continue to recommend routine annual pelvic exams?
Because we find stuff! Things I have found on routine pelvic exam- cervical polyps, vaginal infections, fibroids, Bartholin’s cysts (swelling of a gland near the vaginal opening), warts and…foreign bodies. Old tampons, condoms, not to mention other bits of fun accidentally left up there. But, I digress.
Oftentimes, I notice vaginal discharge, redness or swelling, bumps or blisters in patients without complaints. I’ll say, “Have you noticed this bump here?” And she says, “Oh yeah, that’s been there a few months.” It either didn’t cross her mind to tell me (she may have thought it was normal), or she was too embarrassed to mention it. Or sometimes, a woman will complain of pain during an exam, and only then will she tell me it hurts when she has sex. These are the women I worry about if we skip annual pelvic exams.
And I’ll go ahead and out myself. I am a slacker when it comes to annual exams for myself. I have always pushed them off as long as possible. If annual Pap smears were the recommendation, I would skip a few years if all was normal. Now that Pap smears can be done every 3 to 5 years (if normal), I worry that women will skip 5 to 10 years if we aren’t even examining them.
So, I counsel my patients on these recommendations. If they truly have no symptoms, and have significant anxiety, fear or embarrassment about pelvic exams, we discuss the option to wait until symptoms arise or she is due for a Pap smear. I do ask that she come back yearly for at least a discussion of her reproductive health- STIs, contraception, etc. And surprisingly, most women actually prefer to have the exam. Maybe because they went to all the trouble to shave. Which is fine with me.
And we do appreciate a pedicure.
Georgia Ragonetti-Zebell, MD is an OB/GYN practicing in Upstate South Carolina, and is mommy to four (yes, FOUR) boys. She is a graduate of the Women’s Health Pathway at Drexel University College of Medicine in Philadelphia, Pennsylvania and completed her residency in Obstetrics and Gynecology with the Greenville Health System in Greenville, South Carolina. She has a special interest in natural childbirth, breastfeeding, and alternative methods in labor and delivery. She enjoys yoga, crochet, and reading, but spends most of her free time cleaning up poop while trying not to step on Legos.