Tuesday, May 26, 2015

Another strike against annual pelvic exams?

- Jennifer Middleton, MD, MPH

Despite changes in cervical cancer screening guidelines and the lack of an evidence base to support it, many physicians are still recommending and performing annual pelvic exams. The May 15 issue of AFP reviews the new recommendation from the American College of Physicians (ACP) about annual pelvic exams; similar to many others in the last few years, the ACP finds only harms associated with screening pelvic examinations that are not associated with cervical cancer screening.

The ACP performed a systematic review that included both benefits and harms of annual pelvic exams. They found that pelvic exams did not help women to live longer or better; detection rates of both ovarian and cervical cancer were unchanged. Admittedly, the authors found no studies assessing rates of asymptomatic pelvic inflammatory disease or cancers other than ovarian or cervical, but they did find:
Many false-positive findings are associated with pelvic examination, with attendant psychological and physical harms, as well as harms associated with the examination itself. Harms of pelvic examination include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort. 
The AFP Community Blog has tackled this subject twice before; in 2013, Dr. Lin reviewed the lack of evidence to support the reasons clinicians give for continuing this practice, and in 2014, he discussed an earlier iteration of the ACP's recommendation and connected it to the Choosing Wisely recommendation against the annual physical exam. Despite ever-increasing objections and a lack of supporting evidence, subjecting women to annual pelvic exams - sometimes still accompanied by an annual pap test - remains a common practice. The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend annual pelvic exams for women aged 21 and up, though they acknowledge the lack of evidence to support this stance. It's not hard to find appeals from OB/GYNs to continue this practice, however; they argue that the annual gynecologic visit provides the benefit of reassurance to women when everything "looks normal" and the opportunity for physicians to uncover embarrassing complaints that might, otherwise, have gone unvoiced.

Doing less in health care is hard, and changing practice habits can be difficult, especially when specialty organizations disagree. Family physicians, historically, have depended on other specialist organizations to provide us with guidance about caring for patients with various conditions. Unfortunately, the narrowed patient populations that those specialists see in practice are often quite different than the broader, undifferentiated population seen by primary care physicians. Family physicians should not hesitate to follow population-based screening recommendations oriented to primary care that deviate from other specialty organizations who care for different subsets of patients.

The United States Preventive Service Task Force (USPSTF) is currently preparing to issue an recommendation regarding annual pelvic examination, so stay tuned; in the meantime, the AFP By Topic on Health Maintenance and Counseling contains several helpful resources.

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