Wednesday, January 2, 2013

Questioning the need for annual pelvic examinations

- Kenny Lin, MD

New Year, time for women to schedule their annual pelvic examinations? Not so fast. An editorial that accompanies AFP's Jan. 1 cover article on health maintenance in women challenges this longstanding tradition. This is not the first time that this topic has appeared in the journal; a Curbside Consultation published in 2003 raised similar concerns:

My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.

In their editorial, Drs. Giang Nguyen and Peter Cronholm observe that the reasons that clinicians commonly provide for continuing to perform these "routine" examinations are inconsistent with evidence-based recommendations. Cervical cancer screening should be performed no more often than every 3 years; ovarian cancer screening is ineffective and likely harmful; contraceptive prescriptions need not be preceded by a pelvic examination; and urine samples are highly accurate at detecting asymptomatic sexually transmitted diseases. The authors conclude:

Taking into account the time required for the patient to undress, the time to obtain the necessary equipment, and the time to perform the procedure, a screening pelvic examination can conservatively add an extra 10 minutes to an office encounter. In addition, because many physicians also require a nurse or medical assistant in the room during this examination, there is an opportunity cost associated with the other work that could have been done by the support staff during this time (e.g., stocking supply cabinets, performing immunizations, making phone calls to patients). Given the lack of evidence to support annual pelvic examinations, it would be better for patients if we spend that time addressing screening, counseling, and other preventive services for which strong evidence exists.

Although evidence supporting an unequivocal benefit of routine examinations (pelvic examination or no) remains elusive, many effective clinical preventive services for women can be provided at health maintenance-oriented visits or in the context of care for other health concerns. The review and patient education handout by Dr. Margaret Riley and colleagues, along with additional content in the AFP By Topic collection on Health Maintenance and Counseling, provide excellent summaries of these services.