New ACP guidelines recommend against regular pelvic exams

1. New American College of Physicians (ACP) guidelines recommends against screening pelvic exams for asymptomatic, nonpregnant adult women (strong recommendation based moderate quality evidence). 

2. Women who are victims of sexual violence or who are overweight are more likely to be harmed by a pelvic exam. 

Evidence Rating Level: 3 (Average)        

Study Rundown: The pelvic examination has been a mainstay of the well-woman visit for many decades. Screening pap tests are associated with reduced mortality from cervical cancer. However, the pelvic exam’s usefulness for the detection of other gynecological conditions is unclear. The authors of the ACP’s guidelines and the associated evidence report found that a pelvic exam is inferior to other screening tests, including transvaginal ultrasound and the CA-125 blood test, for detecting ovarian cancer. There were no studies that reported the benefits of a routine pelvic exam to screen for ovarian cancer or other gynecological conditions. Conversely, previous studies have shown that around 30% of women experienced pain and anxiety during the pelvic exam. Women who have experienced sexual violence or who are overweight are more likely to encounter these examination-related harms. Based on this limited evidence, the ACP recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women. It is worth noting that the evidence review that prompted this recommendation found no studies that addressed the diagnostic accuracy or the morbidity and mortality figures for the pelvic examination. Also, the studies that were included in the review were of low quality. It is clear that stronger studies on the benefits and harms of the pelvic examination are needed for future recommendations.

Click to read the study in the Annals of Internal Medicine

Click to read an accompanying editorial in the Annals of Internal Medicine

Relevant Reading: Do new guidelines and technology make the routine pelvic examination obsolete?

In-Depth [systematic review]: The evidence review was conducted by the Minneapolis VA Health Care System and included English-language articles published from 1946 to January 2014. Outcomes of interest included mortality, morbidity and harms. Three cohort studies assessed the diagnostic accuracy of the pelvic exam for ovarian cancer; the combined data showed only four cases of ovarian cancer detected over one year (PPV 0% to 3.6%). No studies that assessed the pelvic exam’s effect on morbidity and mortality rates for non-cervical gynecologic cancers, PID, bacterial vaginosis and other benign conditions could be found. Regarding examination-related harms, fourteen surveys and one longitudinal cohort study found that 11% to 60% (median 35%) of women reported pain or discomfort during the exam, and 10% to 80% (median 34%) of women reported fear, embarrassment or anxiety. Nine studies showed that women who have a history of sexual violence are more likely to experience physical or emotional distress during a pelvic exam than women without such a history.

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