Pelvic examinations to screen women for cervical cancer
do more harm than good, according to controversial new guidelines from the American College of Physicians. The exam rarely detects important disease, does not reduce mortality and is associated with discomfort, false positives and negatives, and extra cost, authors of the report say.
The bimanual exam, which requires a practitioner to insert two fingers into a woman to check her cervix, is often considered uncomfortable and painful, and causes fear and embarrassment for some women. The ACP recommends against giving the test to asymptomatic, nonpregnant, adult women and says when screening for cervical cancer, exams should be limited to visual inspection of the cervix, and cervical swabs for cancer and HPV.
Researchers conducted a systematic review of 52 studies published within the past five years that looked at routine screening pelvic examinations in asymptomatic, nonpregnant, average-risk women seen in outpatient settings. The results of the study were published Monday in the Annals of Internal Medicine
The American College of Obstetricians and Gynecologists defended its guidelines supporting the routine use of the exam. “The college continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction,” the statement said.
In August 2012, an ACOG committee recommended
the test be performed annually on all patients aged 21 and older, and said it is always an appropriate part of a comprehensive evaluation for high-risk patients.
“While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients. Pelvic examinations also allow gynecologists to explain a patient's anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician.”
In an editorial accompanying today's announcement, Dr. George Sawaya and Dr. Vanessa Jacoby of the University of California at San Francisco argue that the pelvic exam has become more of a ritual than an evidence-based practice.
“Ending such a prevalent practice …will be met with formidable challenges,” they said. “Clinicians who continue to offer the examination should at least be cognizant of the uncertainty of benefit and the potential to cause harm.”
The ACP's new guideline is consistent with the stance of the American Cancer Society, which has not recommended bimanual pelvic exams in asymptomatic patients for the past decade, according to Dr. Richard Wender, chief cancer control officer for the American Cancer Society. He said a big concern regarding the exam is the potential for creating false positives, leading to unnecessary medical tests and procedures. But he remained doubtful that clinicians who were trained to perform such tests as part of good preventive screening techniques would be quick to stop solely based on the new guideline.
“Frankly, we're taught learning to do this exam well is a part of being a good clinician,” Wender said. “I don't think we stopped when the ACS removed the recommendation 10 years ago, and I don't think clinicians are going to stop doing it now.”
Wender said he hoped that the ACP guideline encouraged more women to have discussions with their clinicians about their concerns about having the exam.
“I think it's appropriate for patients to ask about the care they're receiving,” said Dr. Linda Humphrey, co-author of the guidelines and a member of ACP's Clinical Guidelines Committee. “I think we physicians, physician organizations and the press really need to help the public begin thinking about the things that are done for tradition as opposed to evidence-based.”Follow Steven Ross Johnson on Twitter: @MHsjohnsonFollow Sabriya Rice on Twitter: @MHsrice