You've likely heard that a doctor's group now says that you can probably skip the annual pelvic exam if you aren't pregnant or having any problems. But don't start jumping for joy just yet.
Another doctor's group (of course) isn't all that happy with the new guidelines, which were issued by the American College of Physicians, or ACP. The ACP says that some parts of the pelvic exam (palpitating the ovaries, for example), aren't all that helpful, rarely detecting important diseases or saving lives, and that they're uncomfortable and cost extra. The American College of Obstetricians and Gynecologists begs to differ.
The ACP guidelines, based on a survey of medical literature from the past 70 years, contradict those issued by ACOG, which still recommends annual pelvic exams for all women 21 years of age and over.
"I feel that [the ACP guidelines] are based on limited data and that annual pelvic exams do offer benefits so they shouldn't be discontinued as routine exams," says Taraneh Shirazian, MD, assistant professor of obstetrics, gynecology, and reproductive science at Mount Sinai's Icahn School of Medicine in New York City and a former ACOG board member.
What is a pelvic exam?
Most women are all too familiar with the routine pelvic exam. The complete exam consists of an external look at the vulva, an internal look at the vagina and cervix with a speculum (a plastic or metal instrument), a Pap smear to test for cervical abnormalities and the "bimanual" exam.
It's the speculum and bimanual portions of the exam that have been questioned by the ACP. The bimanual (in this case meaning "two hands") exam is a relatively low-tech procedure: A healthcare professional inserts one or two gloved fingers into a woman's vagina while pressing the abdomen with the other hand. This is supposed to enable doctors to feel the uterus, ovaries, and fallopian tubes.
It serves as a baseline assessment of the uterus and ovaries," says Dr. Shirazian. "That way, the physician can monitor changes over time and is more likely to detect early and small abnormalities such as fibroids and cysts."
Much of the discussion around pelvic exams has centered on its potential value in detecting ovarian cancer, which is notoriously difficult to diagnose and often isn't found until it's in an advanced stage. Pelvic exams are more helpful in conjunction with other tests such as a blood test to detect the protein CA-125—but not so much on their own, says Dr. Shirazian.
The possible healthcare fallout
Still, there are other benefits to pelvic exams and maybe even considerable harm in foregoing the bimanual and speculum portions.
"The thing that concerns me is that this will limit access to care for women," says Dr. Shirazian. "If there are national guidelines saying women don't need [the pelvic exam], there may be push-back from insurance companies to cover it."
Dr. Shirazian points out that mammograms and Pap smears have also recently come under scrutiny, raising concerns that those tests might be dropped by insurance plans. And while there may not be a lot of data on the pelvic exam's benefits, nor are there a lot of data to support not doing it, she adds.
It's unclear what effect issuance of the new guidelines will have either on healthcare coverage or on practice. Different doctors may respond in different ways.
The organization that issued the controversial new guidelines, the ACP, represents internists, some of whom practice as family physicians. The ACP also has guidelines for other conditions including diabetes, chronic obstructive pulmonary disease (COPD) and erectile dysfunction. ACOG represents specialists in the area of women's reproductive health.
Both gynecologists and family physicians perform pelvic exams, with family physicians likely performing them more often than gynecologists in areas with limited access to healthcare, says Dr. Shirazian.
Who still needs the exam
ACP does support pelvic examinations if women have vaginal discharge, abnormal bleeding, pain, or other pelvic symptoms. Though ACOG has noted that the bimanual exam has some "limitations." For example, it's better at detecting abnormalities of the uterus than those in the fallopian tubes or ovaries.
For her part, Dr. Shirazian says that patients who feel uncomfortable with the pelvic exam because of prior sexual abuse (or any other reason) should at the very least discuss the pros and cons of the exam with their doctor or provider.
Otherwise, women "should continue getting it," she says. "It is part of the physical exam just like we examine the heart and the lungs, all the structures in the body that we can."
Many women, she adds, "feel reassured by a normal pelvic exam."
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