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Commentary


Is the annual pelvic exam a relic or a requisite?

Recent publications have questioned the value of a comprehensive pelvic exam in asymptomatic women

April 2011 · Vol. 23, No. 4

The annual pelvic examination has been in the spotlight lately. After a commentary questioning its value was published early this year in the Journal of Women’s Health, the Wall Street Journal highlighted the controversy in its own high-profile article.1,2

At issue is a simple question: Does the pelvic examination deter women from seeking gynecologic care?

Some argue that the exam is so unpleasant that many women avoid their doctor’s office rather than undergo it. Here is the Wall Street Journal’s take on the issue. It’s the first line of its article on the subject:

Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.

The authors of the original commentary in the Journal of Women’s Health are a bit more circumspect. Carolyn L. Westhoff, MD, MSc, and colleagues discuss the reasons that a pelvic examination is traditionally performed—to detect sexually transmitted disease, clear a woman for contraception, and screen for cancer—and present evidence suggesting that these indications for the pelvic exam are no longer absolute in asymptomatic women.1

For example, Chlamydia can be identified in a culture obtained from urine or on vaginal swabs collected by the patient herself. Birth control pills can be prescribed without examining the patient as long as she is in good health and reports no problems. And evidence suggests that the pelvic exam—including bimanual palpation—does not increase the detection of ovarian cancer in asymptomatic women.

And now that ACOG has raised the minimum age for cervical cancer screening to 21 years and extended intervals between Pap tests for women who have normal results, there is no reason to examine the cervix every year, Dr. Westhoff and colleagues argue. In young women, annual inspection is unnecessary because cervical dysplasia tends to be transient, and, in older women, cervical inspection is unnecessary because a simple human papillomavirus (HPV) test can yield just as much information as a Pap smear and can be conducted on self-collected vaginal swabs.

So the question remains: Is the annual pelvic exam really required?

I would argue that the answer is “Yes.”

The pelvic examination offers many benefits

I find the pelvic exam to be indispensable in the assessment of the vulva, vagina, pelvic floor, and sexual function—and it yields information I often cannot obtain in any other way. For example, some vulvar lesions produce no symptoms but still pose a risk of cancer or represent a developing problem such as lichen sclerosis, but I cannot identify them unless I see them.

The physical examination of tissue also prompts me to ask focused questions, frequently about things the patient is too embarrassed to bring up herself. For example, I may examine a woman and find a cystocele or urethrocele. If she hasn’t mentioned leaking urine or other difficulties, the discovery prompts me to ask more specifically about these symptoms. When I do, I often uncover a significant source of distress that, for whatever reason, the patient did not report herself.

Other examples: On occasion, during the pelvic examination, I discover vaginismus. That finding prompts me to ask about painful sex. And sometimes a perimenopausal woman has dry vaginal tissue that is not bothersome…yet. By identifying this condition early, I can suggest interventions that prevent the dryness from becoming bothersome.

Validation is another benefit of the pelvic exam. For example, some younger women think they “look weird” or have something wrong with their body, and my reassurance that everything is totally normal can greatly ease their mind.


The power of ritual

In a New York Times article about the need to focus on the actual patient rather than simply the data in her chart, Abraham Verghese, MD, relates the story of an elderly patient whose daughter was resistant to his recommendations until she watched him perform a comprehensive physical exam.3 The medical team discussed the case afterward and concluded that “the daughter witnessing the examination of the patient, that ritual, was the key to earning both their trusts.”3

“I find that patients from almost any culture have deep expectations of a ritual when a doctor sees them,” Dr. Verghese writes, “and they are quick to perceive when he or she gives those procedures short shrift by, say, placing the stethoscope on top of the gown instead of the skin, doing a cursory prod of the belly and wrapping up in 30 seconds.”3

I agree. Patients can be very resistant to our recommendations if they feel they have gotten substandard evaluation. And part of their expectation of evaluation is a physical examination. There is a sense of connection and closeness that patients have come to count on. And they can tell when we are not placing enough emphasis on this aspect of care.

Another argument in favor of the pelvic exam: I see at least one patient every day who is referred to me by her primary care doctor and who has not, over the course of her care for the current complaint, had to take off her clothes for a comprehensive examination. She typically is sent to me because of a finding on magnetic resonance imaging (MRI) or computed tomography (CT). Not uncommonly, women are convinced they have cancer based on these incidental findings. Yet those findings usually turn out to be a perfectly benign entity of little consequence, such as a benign fibroid tumor of the uterus. The power of the physical exam is that it can document things such as fibroids before they turn up on an MRI or CT scan. That is much less stressful for the patient than having a mysterious lesion identified on imaging, necessitating referral to a specialist to identify the problem.

No barriers to care

I don’t think women like the pelvic exam any more than they like mammograms or being physically vulnerable in any way. In my experience, however, patients tend to experience more trepidation about stepping onto the scale than about undergoing a pelvic exam.

Am I going to create a barrier to a patient’s care by insisting on weighing her or on performing a pelvic exam after she voices her desire to avoid these things?

Of course not.

Certainly, if a patient declines either of these options, I honor her wishes. However, I make it a point to have a conversation with her about their intrinsic value.

I try to teach my patients that they are the owners of their bodies, and that everything that occurs in the doctor-patient relationship is collaborative. In my practice, women always have the option to say “No.”

I do agree with Dr. Westhoff and colleagues that some women are turned off by the prospect of a pelvic exam. Adolescents, in particular, are often apprehensive about it. When I see a teenager for her first gynecologic visit, I usually focus on discussion. I try to get to know her and attempt to give her a sense of control over her own body. When it comes to the pelvic exam, I give her a choice—and I honor her decision.

Other patients who may be unwilling to undergo an annual pelvic exam include women who have a history of sexual abuse or molestation. Again, I respect their wishes, but I do talk to them about the value of the physical.

Unlike Dr. Westhoff and colleagues, however, I don’t believe that “no annual pelvic exam” should be our default position. And although there are other components of gynecologic care to see to besides the pelvic exam, I don’t think the exam should be dispensed with in the interest of saving time. In actuality, the pelvic exam is probably the least time-consuming aspect of gynecologic care for an asymptomatic patient.

In my view, the purpose of the annual visit is to identify risks and manage them—and some risks may be overlooked if I don’t have the opportunity to examine the patient. At the annual well woman visit, I have a conversation with the patient about the risks she faces over the next year, depending on her age and overall condition, and I devote quite a bit of time to this discussion. But I don’t do it at the expense of a careful pelvic exam.

Instead, I honor the ritual and the critical information it yields.


INSTANT POLL: A patient arrives for her annual well-woman examination. What do you do?
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References

1. Westhoff CL, Jones HE, Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete? J Women’s Health. 2011;20(1):5-10.

2. Beck M. Questioning the need for routine pelvic exam. Wall Street Journal. February 15 2011. http://online.wsj.com/article/SB10001424052748703584804576144161119909004.html. Accessed March 10, 2011.

3. Verghese A. Treat the patient not the CT scan. New York Times. February 26, 2011.http://www.nytimes.com/2011/02/27/opinion/27verghese.html. Accessed March 14, 2011.

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