See You Later, Speculum
The case for getting rid of annual pelvic exams.
When I was in my 20s and 30s, as for millions of other healthy young women, the only doctor I visited regularly was my gynecologist. I had no medical problems, so I saw no reason to have an internist, even though I had chosen to become one myself. Yet every year I'd dutifully make my OB-GYN appointment and endure the stirrup-and-speculum ritual of the pelvic exam: the circling of the little spatula around my cervix, the twirling of the spiky pipe cleaner, the prodding of my uterus and ovaries. It was always reassuring to get the exam, and equally reassuring to get it over with. Whatever else we discussed—birth control, STD prevention, my diet, stress management—seemed like icing on the cake. The pelvic exam, and in particular the Pap smear, was the main event. Even though I'd probably had close to 20 normal exams by the time I hit 40, it always seemed essential that I get another one every year. And until recently, most other doctors thought so, too.
But an article in Journal of Women's Health earlier this year declared, convincingly, that the routine kitchen-sink-and-all pelvic exam should be relegated to the medical archives. In a distinct departure from the conventional wisdom, the authors write that there's no compelling reason why women without symptoms or risk factors should be getting these exhaustive exams—and that even the Pap smear, instilled in the minds of most women over 30 as a necessary yearly ritual, isn't needed as often as once thought.
Some of the main reasons for conducting a routine pelvic exam are the early detection of cervical and ovarian cancer, screening for chlamydia, and as a prerequisite for prescribing hormonal birth control. But as the Journal article authors note, with the exception of cervical cancer (which we'll get to in a minute), each of these goals can be addressed with a better or cheaper method—if it needs addressing at all.
To evaluate the ovaries, for example, gynecologists employ the bimanual exam. With two fingers in the vagina and the other hand on the belly, the OB-GYN feels the uterus and ovaries to note the presence of any abnormalities. Unfortunately, there's no medical evidence that this poking and pressing can reliably detect ovarian cancer in its early stages. In fact, for average-risk women, there's no good screening test for ovarian cancer—not the bimanual exam (early ovarian cancers are notoriously difficult to feel, which is why they're often already widespread when diagnosed), nor ultrasounds nor blood tests. Until scientists develop a reliable method of early detection—some ovarian equivalent to the Pap smear, colonoscopy, or mammogram—the best we can do is educate women to report such symptoms as bloating, feeling full quickly, and pelvic pain.
Meanwhile, though chlamydia testing is traditionally done on a cervical sample collected during a speculum exam, a urine sample or a self-administered vaginal swab works just as well and costs less. And although some doctors still insist on a pelvic exam as a prerequisite for prescribing oral contraceptives, there's no medical reason for that practice. (It's a different story for an IUD or a diaphragm, which must be fitted to the individual woman.)
Gynecologists take note of many other conditions during the course of a routine pelvic exam. But unless these conditions are causing symptoms—such as vaginal discharge, itching, pain, or bleeding—the information gathered is unlikely to change what the doctor does next. Yeast infections and bacterial vaginosis, for example, usually resolve themselves without treatment. Uterine fibroids may sound scary, but unless they're causing symptoms (such as bleeding between periods or pelvic pain), there's no evidence that diagnosing them has any benefit. And while noting the size and position of the uterus makes sense if you're a medical student studying anatomy, it doesn't really matter to a doctor whose patient isn't pregnant and is otherwise healthy.
Anna Reisman is a physician in Connecticut. You can follow her on Twitter: @annareisman.
Photo by Keith Brofsky/Thinkstock.