A pelvic exam for women who are not pregnant and do not have symptoms of cancer may be unnecessary, says the American College of Physicians (ACP) in a controversial new set of guidelines published Monday in the Annals of Internal Medicine. The ACP, which reviewed studies on the harms and benefits of pelvic exams, says the procedure does not detect disease as well as previously thought; it doesn't reduce mortality; and it leads to many false positives, resulting in unnecessary testing and anxiety.
For the uninitiated, here's what happens when women visit the gynecologist: their legs go up in stirrups and the doctor looks at the genitals before inserting a speculum into the vagina to examine the cervix. (If a woman is getting a Pap smear, cervical cells are gently scraped off with a Q-tip-like tool.) Then, the doctor places one hand inside the vagina and the other on the abdomen and feels for anything that isn't right on the ovaries and uterus. In some cases, the doctor inserts a finger into the rectum for the same purpose. This is the pelvic exam.
While the process is not painful, it's certainly invasive. Now, ACP is questioning the necessity of this part of the checkup — commenting that "pelvic examination can cause anxiety, discomfort, pain, and embarrassment, especially in women who have a history of sexual abuse."
But their guidelines are not being met with widespread praise. "I think in the obstetrics and gynecology world, everyone will laugh at this and think this is the silliest thing they have ever heard," says Dr. David Fishman, a professor and director of gynecologic oncology research at Mount Sinai Hospital. "As a gynecological oncologist, my whole career has been spent on women who have no symptoms, and then an abnormal mass is found."
Just on Monday, Fishman met with a young, healthy woman who had a mass on her ovary she had no idea was there. "We all know the pelvic exam is flawed. It’s not comfortable for the patient, some doctors do not like doing it." says Fishman. "Maybe statistically [the pelvic exam] doesn’t make a difference, but to that family, you’ve saved a life."
The American Congress of Obstetricians and Gynecologists (ACOG), considered the authority on reproductive health, still recommends yearly pelvic exams for women 21 years and older, though in a 2012 committee opinion, ACOG acknowledged that the "limitations of the internal pelvic examination should be recognized."
The new recommendations open the doors to continued debate over physical exams, and when they are appropriate.