Annual pelvic exams: The case for getting rid of them.

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July 5 2011 2:31 PM

See You Later, Speculum

The case for getting rid of annual pelvic exams.

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Even the Pap, long the star of the annual well-woman exam—and one of the most dependable, effective, tried-and-true cancer screening methods of all time—is needed less often than we currently provide it. That's in part due to the discovery that nearly all cases of cervical cancer are directly linked to infection with certain high-risk types of HPV, or human papillomavirus. During a pelvic exam, a doctor collects cervical cells, which can be "co-tested" for pre-cancerous cellular changes (via the Pap) and, in women between 30 and 65, for HPV. (HPV testing isn't recommended for women under 30, since the infection is very common at that age and usually goes away on its own.) If a woman's Pap is normal and she tests negative for HPV, then the chances of her developing cervical cancer in the next several years are incredibly small.

In 2009, thanks to advances in HPV testing and also to years of studies showing that, when part of an organized cervical-cancer screening program, annual testing is no better than less frequent testing, the American College of Obstetricians and Gynecologists recommended reducing the frequency of Pap smears. Assuming a woman's Paps are consistently normal and that she has no risk factors—such as HIV or a history of cervical cancer—she should have her first Pap at age 21; every two years between the ages of 21 and 29; and, as long as she's had three consecutive negative Paps, every three years between ages 30 and 65. This prevents unnecessary testing—especially in adolescent women, who despite frequent transient HPV infections rarely get cervical cancer—and overtreatment, with its financial and emotional costs.

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For many clinicians long accustomed to the annual pelvic and Pap, it's been hard to get comfortable with the multiyear recommendation. These exams are, after all, the bread-and-butter of the annual well-woman GYN visit; doctors worry that spacing them out may lead to litigation, difficulty getting reimbursed, and the loss of their primary-care role. And despite the new ACOG guidelines, many doctors remain concerned about whether taking a break is safe, thanks to the long-ingrained notion that annual exams were nonnegotiable. A new reportpublished a few weeks ago in Lancet Oncology may ease that fear: A large study of 330,000 women determined that the three-year interval for Pap/HPV co-testing is, indeed, medically sound. Women who had a normal Pap and a negative HPV test had a very low risk of developing cancer over the following five years: just 3.2 per 100,000 women per year. Compared with breast cancer, where the incidence is about 124 per 100,000 women per year, the risk is impressively tiny.

Some ladies, no doubt, will cheer the idea of spending less time in the stirrups. Others may miss the ritual aspect of the comprehensive exam—the laying on of hands, the time taken to methodically examine, probe, and palpate. But whichever camp a woman falls into, she shouldn't abandon her yearly well-woman exam, even if she does ditch the annual routine pelvic. If anything, your gynecologist visit will now be even more complete, with time to address a litany of important issues often overshadowed by the pelvic exam: screening for intimate-partner abuse, family planning, physical activity, nutrition, smoking, bone health, breast cancer screening, sexual health, stress management, blood pressure—the list goes on. If the doctor with whom a woman feels most comfortable discussing these issues is her internist, fine. If it's her gynecologist, why should she stop going simply because she doesn't need to get on the table? After all, there's more to screening than a speculum.

Anna Reisman is a physician in Connecticut. You can follow her on Twitter: @annareisman.