The ACP's new evidence-based clinical guideline, "Screening Pelvic Examination in Adult Women," will be published tomorrow in the ACP’s flagship journal, Annals of Internal Medicine.
According to the ACP, when screening for cervical cancer, the examination should be limited to visual inspection of the cervix and cervical swabs for cancer and human papillomavirus (HPV), and does not need to include the biannual examination. ACP found that the diagnostic accuracy of pelvic examination for detecting gynecologic cancer or infections is low. ACP advises that the pelvic examination is still appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.
Emphasizing that this guideline only applies to pelvic examinations, and not to Pap smear screenings for cervical cancer, Dr. Linda Humphrey, a co-author of the guideline and a member of the ACP's Clinical Practice Guidelines Committee, said in a press statement, "Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality, and is associated with discomfort for many women, false positive and negative examinations, and extra cost."
Guideline Stirs Controversy Among Experts
Dr. Sandra Fryhofer, a past president of the ACP and a practicing internist, told Healthline that the guideline "will be very controversial, but in so many ways this is very exciting for women. It’s a reflection of further fine-tuning of what women need and what they don’t need, what is necessary and what might be unnecessary, and what could actually cause harm."
But Dr. David Fishman, a professor of obstetrics, gynecology and reproductive science at the Icahn School of Medicine at Mount Sinai Hospital in New York, told Healthline, "I think the guideline compromises women’s healthcare. The comment suggesting an annual pelvic exam has no value, as a gynecologic oncologist, is ridiculous. Is healthcare the motivating factor or is it financial? Already women are being compromised because insurance companies don’t want to pay for Pap smears or for annual mammograms. So what’s next; don’t go for an exam?"
Pointing out that there are exceptions to the new guideline, Fryhofer said, "[The guideline] also doesn't address symptoms in women who are at increased genetic risk, or with a personal family history of [gynecological] cancers."
Fryhofer went on to say, "For routine screening, the guideline is a hallelujah for women. Certainly, the pelvic exam is uncomfortable; it is sometimes painful, often embarrassing, and it triggers a lot of anxiety in some women. The ACP's perspective is when the harms of a test or an intervention outweigh the benefits, it should not be done. There are guidelines, not rules. We encourage patients to engage in shared decision making with their physician and to bring up any concerns they have."
Acknowledging that the pelvic exam prompts women to visit their doctor, Fryhofer said, "They still need to get regular cervical cancer screenings, which are the Pap smears. The guidelines now say to start at age 21, and do Pap smears every three years for screening, and no screening after 65. When you get that Pap smear, you don’t have to have the biannual."
Fishman contends that this is not enough. "The message that is being sent is highly questionable. As a gynecologic oncologist, the majority of women referred to us are women who have gynecologic abnormalities...and often the patients are asymptomatic. I just saw a woman who presented feeling perfectly fine, and her doctor did a biannual pelvic exam and found a 15 centimeter mass that turned out to be cancer. She had no symptoms. As 80 percent of the women who are found with ovarian cancer have no family history or risk factors, I think with respect to ovarian cancer, this is a joke," Fishman said. "Next they will be saying that an annual exam for men should not include a prostate exam, or somebody listening to their lungs or heart."
Fryhofer said that doing the exam simply because it is routine would be a mistake. "This guideline will make sure we ask patients about their symptoms rather than just by reflex doing the exam," she said. "It’s exciting that the study’s authors were looking at what women need and don’t need. It adds full disclosure to patients about the value of exam, the benefit, and the possible harm.”
Are Young Women at Risk?
Fishman believes the health of younger women is a particular cause for concern "because what we have now is a society where women have their babies, where they are constantly screened and evaluated, and then they don’t see a physician again until they have problems in their 60s and 70s, which is a horrible statement."
Dr. Taraneh Shirazian, an assistant professor of obstetrics, gynecology and reproductive science at Mount Sinai, told Healthline, “Even in asymptomatic women, [a pelvic exam] allows the gynecologist the opportunity to perform a baseline exam and detect early abnormalities of the uterus and adnexal structures.”
Shirazian concluded that pelvic exams are a key part of tailoring healthcare to the needs of each individual. “As the woman continues to follow with her gynecologist over time, ongoing exams allow the opportunity to detect changes and diagnose new abnormalities in the individual woman," she said. "It is an important piece of comprehensive healthcare for women, and is part of the American College of Obstetricians and Gynecologists (ACOG) national screening recommendations.”