When I was the medical director of the Sonoma County Public Health outpatient clinics, which included the Family Planning and STD clinics, I would commonly discuss the lack of need for a bimanual exam of the, typically, young women who used our services if they were without symptoms. I would encourage the clinicians to take a good history, get the Pap specimen when needed, and inspect the perineum, vagina, and cervix at that time, collect screenings for chlamydia/CG, and get out. The bimanual exam was likely a waste of time, uncomfortable, and embarrassing for the women, which might pose a barrier to accessing our important services. The discussion would rage on.
Well, now the ACP has come out with a guideline statement which concludes there are no data to support the pelvic examination in asymptomatic, average-risk women. Their statement did not alter the need for cervical cancer monitoring and Pap testing, nor did it address the evaluation of women with symptoms or those at high risk of problems.
There were also low-quality data which suggested pelvic examinations cause pain and discomfort (duh!), fear, anxiety, and embarrassment in about 30% of women.
Three of the studies reviewed for the detection of ovarian cancer had positive predictive values ranging from 0% to 3.6% but no studies were found showing the bimanual examination useful in detecting other malignant or benign conditions.
On the other hand, ACOG recommends that speculum and bimanual exams be part of the annual well-woman visit in women 21 and older and that “despite lack of evidence about the value of internal examinations, decisions about performing such examinations should be made jointly by clinician and patient ‘after sharing communication and decision making.’” ACOG goes on to say, “Pelvic examination is not a prerequisite to testing for STDs or to initiating oral contraceptives in healthy, asymptomatic women.”
A flurry of online commentary followed the ACP posting, from supportive to oppositional and a lot of anecdote.
Some argued that the annual pelvic exam afforded the benefit of a regular visit to the doctor (not certain this is true or could not be accomplished in other ways — and this could be seen as a disingenuous ruse to entice).
Not commonly discussed is the potential time saved for both the clinician, medical office, and patient. Time that might be put toward other useful purposes.
Marshall Kubota, MD