The Controversy over Routine Pelvic Exams–Dr. Favor Responds

You may have heard or read this month that a physicians’ group has stated that women no longer need an annual pelvic exam if they have no gynecologic symptoms. Your physicians at Sparks & Favor still recommend a pelvic exam to our patients as an important part of your annual well-woman exam.

We take very seriously our responsibility to provide the up-to-date information you need to make decisions about the benefits of exams, tests, or treatments we recommend, as well as any potential risks.

Facts about this very controversial recommendation include:

  • The new recommendation came from the American College of Physicians (ACP). It is the professional organization of internal medicine physicians, NOT physicians who specialize in women’s care.
  • The ACP based its new recommendation on research done in the past—mostly to question whether the pelvic exam could detect ovarian cancer. Physicians generally agree that the pelvic exam is not a good screening tool for this very dangerous gynecologic cancer.  At your annual exam, we review your risk factors and can recommend appropriate screening for your risk group.
  • The internists for whom the American College of Physicians speaks may rightly feel uncomfortable with an exam for which their training is limited, and which they do not perform regularly.
  • But we believe the ACP stepped seriously outside of its expertise with its recommendation against pelvic examinations for non-pregnant adult women with average risk-factors and no symptoms.

Although a pelvic exam will not usually find ovarian cancer until it has spread beyond the ovary, we still may discover it before the patient has become sick with the cancer. While this difference may not save her life, cancer specialists want to offer her treatment soon as soon as possible to preserve her health for as long as possible.

We get other very helpful information from your exam. We are able to find benign (non-cancerous) enlargements of the uterus (fibroids) or ovaries (cysts and other benign tumors), or changes that suggest endometriosis. Fibroids are usually benign, but the Food and Drug Administration has recently published its estimate that about 1 in 350 fibroids contains cancer.

These benign gynecologic conditions may not threaten your life, but they can cause considerable discomfort, inconvenience, time lost from work, etc. The internists’ group stopped short of saying that pelvic exams offer no benefit to women with benign  problems—saying only that its benefit had not been studied.  We don’t typically research obvious questions like “will my surgery for enlarging uterine fibroids be easier if my doctor finds them early?” If we find an abnormal condition, follow-up exams tell us whether the mass is becoming larger. We want to be able to recommend surgery while a minimally-invasive procedure is possible. To throw aside this standard tool of women’s preventive care because we don’t (yet) have statistical data on its benefits is a risky leap.

And more important, the pelvic examination is only one part of your annual well-woman exam. Women’s physicians are concerned that the ACP statement may cause some women to overlook the importance of receiving yearly preventive health exams. Click here to read more about specific recommendations for your annual health care visit, based on your age.

The ACP defends its recommendation by discussing potential harms of annual pelvic exams, including 1) over-diagnosis and treatment and 2) discomfort, anxiety, or embarrassment. Not much scientific evidence exists about over-diagnosis, but it is a very small potential risk. Women must individually decide whether the information the exam provides is worth accepting that possibility. As a physician and a woman, I don’t think any of us look forward to a pelvic exam. But I believe we are quite capable of deciding for ourselves how much anxiety, embarrassment, or discomfort we feel. For an organization to make that judgment on behalf of all women is paternalistic and disrespectful.

The ACP offers a third reason for abandoning the annual pelvic exam—cost. The darker side of this issue—as with all health-related cost/benefit decisions—is the constant pressure to see how little we can offer in the way of preventive healthcare without doing too much harm. Over the course of my career, I’ve seen the cost-cutters aim their scissors at women’s health benefits many times. In the early 1990s, they told new mothers that they should be quite ready to go home and care for their newborns after only 24 hours in the hospital. Women have had to demand that their state legislators protect their healthcare rights as various managed care plans tried to limit their direct access to Ob-Gyn physicians. In 2009, the U.S. Preventive Services Task Force told women that annual mammograms did not save enough lives to be worthwhile. (Read more). Again, part of their reasoning addressed the anxiety and breast cancer worry that a woman may experience.

As with all medical procedures, pelvic exams are most effective when performed by physicians who regularly perform Gyn exams. A physician who performs pelvic examinations infrequently may not recognize small changes in a woman’s abdomen. But each of us who cares for only women each day can time and again remember a patient whose exam was not what we expected and whose health outcome was improved by that exam. So we will follow the recommendation of American College of Obstetricians and Gynecologists, physicians who specialize in healthcare for women. That organizationcontinues to firmly believe in the clinical value of pelvic examinations…”.

Final note: Do inform your physician about any anxiety you experience anticipating a pelvic exam or any other medical procedure. Especially, inform us of any unexpected discomfort you feel during the exam, as this information is an important part of our evaluation.