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The case against action: notes on the new pelvic exam policy

Posted on July 4, 2014

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New U.S. guidelines suggest an end to the yearly pelvic examination 

The new sermon:

The American College of Physicians (ACP) has published a revised statement that may put an end to the yearly practice of the pelvic exam.

At an annual well-visit

Year after year, women visit with their primary care doctor for their annual exam as an opportunity for routine screening and health maintenance. This includes screening for cervical and ovarian cancers. While cervical cancer is often screened for every 3 to 5 years, an annual pelvic exam, where the doctor looks and feels for abnormalities of the cervix, uterus and ovaries, was indicated. This yearly practice is currently considered a routine standard of care for well-woman visits.

What the ACP found

The ACP reported that, in asymptomatic, average-risk women, there is no data to support the continued practice of the pelvic examination. In fact, in approximately 30% of women, they found data suggesting that the pelvic exam may cause pain, discomfort, fear, anxiety and embarrassment.

Focus on the evidence

To reach this conclusion, the ACP used MEDLINE and Cochrane databases to evaluate the benefits versus harms of the pelvic examination, and its diagnostic accuracy. The population of focus was asymptomatic, non-pregnant, average-risk adult women.

They report that

“the positive predictive value of pelvic examination for detecting ovarian cancer was less than 4% in the 2 studies that reported this metric.” 

You can find a recap on Positive Predictive Value here on Students 4 Best Evidence.

The ACP did not find any studies addressing the pelvic exam’s benefit on morbidity or mortality.

Some additional pelvic exam statistics from the report:

“The percentage of women reporting pelvic examination–related pain or discomfort ranged from 11% to 60% (median, 35%; 8 studies [n = 4576]).”

“Corresponding figures for fear, embarrassment, or anxiety ranged from 10% to 80% (median, 34%; 7 studies [n = 10 702]).”

A new ‘well-visit’ on the horizon?

For women, it is most likely that you can say goodbye to your yearly pelvic examination. That is not to say that the yearly well-women visit isn’t important and is to be replaced, it just means that the pelvic examination procedure may be omitted from the visit. As to when this change will take place, remains to be determined. It is likely that the medical community, including Obstetricians & Gynaecologists may pursue more conversation on the topic before deciding wholeheartedly to omit the practice of the pelvice exam altogether.

In medicine, there is always a duty to “do no harm,” and this includes screening procedures. When the harms, such as embarrassment and pain, associated with a pelvic exam, outweigh the benefits of identifying a potential cancer it’s time for that practice to be re-evaluated. With supporting evidence to retire the pelvic exam, now published by the ACP, look for a hearty debate on the subject to follow.


Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Hanna E. Bloomfield H, et al. Women: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(1):46-53. doi:10.7326/M13-2881

Found online at:  http://annals.org/article.aspx?articleid=1884533

Aaron Sacheli

Aaron Sacheli

Aaron Sacheli is a graduate of McGill University, in Montreal, Quebec and is currently a third year medical student at St. George’s University, completing his clinical rotations in Detroit, MI.

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The case against action: notes on the new pelvic exam policy by Aaron Sacheli is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Unless otherwise stated, all images used within the blog are not available for reuse or republication as they are purchased for Students 4 Best Evidence from shutterstock.com.

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