Are Routine Pelvic Exams A Must? Evidence Is Lacking, Task Force Says | KUOW News and Information

Are Routine Pelvic Exams A Must? Evidence Is Lacking, Task Force Says

Mar 7, 2017
Originally published on March 7, 2017 2:55 pm

An influential advisory panel says there's not enough evidence to determine whether annual pelvic exams should be routine for women who aren't pregnant and have no symptoms of disease.

"We basically concluded that we didn't have enough evidence to recommend for or against," says Dr. Kirsten Bibbins-Domingo, an internist and epidemiologist at the University of California, San Francisco who chaired the U.S. Preventive Services Task Force panel asked to evaluate the best evidence on whether the exam is a good screening method.

Her panel, which calls for more rigorous research on the question, reported its recommendation Tuesday in JAMA, the journal of the American Medical Association. In absence of solid evidence one way or the other, the panel advises that each woman confer with her doctor about when and how often she should get a pelvic exam, given her age, medical history and other factors.

A pelvic exam, typically performed by an obstetrician-gynecologist or other primary care provider, is done to manually check the overall health of a woman's reproductive organs, including the vagina, cervix, uterus, fallopian tubes and ovaries.

Traditionally, the American College of Obstetricians and Gynecologists has recommended the exam annually for all women 21 years of age and older.

"Probably the reason physicians say most often that they think a pelvic exam may be important is for detection of ovarian cancer," Bibbins-Domingo says.

But in 2014, the American College of Physicians, a group representing doctors of internal medicine, published clinical guidelines of its own, challenging the accuracy of the routine exam in detecting ovarian cancer among women who don't have symptoms.

The exam shouldn't be used as a screening tool, the ACP said, because there's no good evidence it picks up ovarian cancer, and the downside of its use among healthy women is significant — false positives can lead to needless anxiety for the patient and additional testing or even surgery that's more invasive and costly.

Anyone who hoped Bibbins-Domingo's independent panel, which included OB-GYNs and internists, would settle the question will be disappointed.

But Dr. George Sawaya, a researcher and OB-GYN from the University of California, San Francisco, who wrote an editorial accompanying the USPSTF recommendations, says the group's call for better research is, nonetheless, significant.

"We live in an era where it's really important to make sure we have really excellent evidence when it comes to prevention," Sawaya says. "We don't want to harm well people in our pursuit of trying to make them more well in the future."

The panel does recommend that any woman with symptoms such as unexplained bleeding, pain or signs of infection consult her doctor right away.

"If a woman has concern about anything going on with her body she should absolutely schedule a visit with her doctor, and doctors should do the appropriate exams to understand symptoms," says Bibbins-Domingo.

And while the ACOG still recommends yearly pelvic exams for all women 21 and older, in a statement issued on Tuesday, the medical society says it plans to evaluate whether it needs to update its guidance on routine pelvic exams.

The federal recommendation still stands, Sawaya says, that every woman age 21 to 65 who has a cervix get a Pap smear every three to five years. There's good evidence, he says, that the periodic Pap test (which is often done in conjunction with a pelvic exam), can be a highly effective screening test for cervical cancer.

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Every year, tens of millions of women get pelvic exams. A new report is questioning the need for such annual tests in healthy women who have no symptoms of disease. It's from a panel of experts from the U.S. Preventive Services Task Force, the same body that makes recommendations on Pap smears, which remain unchanged. NPR's Patti Neighmond explains.

PATTI NEIGHMOND, BYLINE: For most women over 21, the yearly pelvic exam is routine. Doctors examine internal and external reproductive organs to make sure there are no abnormalities. Dr. Kirsten Bibbins-Domingo chaired the task force.

KIRSTEN BIBBINS-DOMINGO: Probably the reason that physicians say most often that they think a pelvic exam may be important is for detection of ovarian cancer.

NEIGHMOND: But no studies have shown that to be true, and that's exactly the kind of evidence the task force was looking for. They wanted to know if there was any scientific data proving that the yearly pelvic exam helped detect disease.

BIBBINS-DOMINGO: We basically concluded that we didn't have enough evidence to recommend for or against the pelvic exam.

NEIGHMOND: Which is why the task force calls for more research to help figure out potential benefits and harms. In the meantime, Bibbins-Domingo says women should consult with their doctor about whether a pelvic exam is warranted.

BIBBINS-DOMINGO: If a woman has concern about anything going on with her body, she should absolutely schedule a visit with her doctor, and doctors should do the appropriate exams to understand symptoms that patients have.

NEIGHMOND: Symptoms such as unexpected bleeding or pain. In an editorial published along with the new policy, OB-GYN George Sawaya with the University of California, San Francisco, says while there may be no proven benefit to the yearly exam, there is a downside - false alarms.

GEORGE SAWAYA: There is certainly a possibility that we're going to find an abnormality that's going to lead to more tests.

NEIGHMOND: Which is the case for as many as 8 percent of all women who have a pelvic exam, and further testing can raise more suspicions. And for these women, up to one-third of patients end up having surgery.

SAWAYA: And most of these were for conditions that were not cancerous, so we could think about those as being false positives and unnecessary surgeries.

NEIGHMOND: Along with all the anxiety and worry about a potential cancer diagnosis. Sawaya says the timing was good to take a closer, more evidence-based look at the value of the pelvic exam.

SAWAYA: We live in an era where it's really important for us to make sure we have really excellent evidence when it comes to prevention because we don't want to harm well people in the present in our pursuit of trying to make them weller (ph) in the future.

NEIGHMOND: The American College of Obstetricians and Gynecologists still recommend annual pelvic exams for women 21 and older but in light of the task force findings plan to evaluate whether it needs to update its guidance. It's important to note the recommendation is not about the Pap smear which is often done along with the pelvic exam. The Pap smear is a proven and highly effective screening test for cervical cancer. The task force recommends women ages 21 to 65 have a Pap smear every three to five years. Patti Neighmond, NPR News.

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