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Reference: Ann Intern Med 2014;161:67
Pelvic examination is a common part of annual health visits for women as a screening method for cancer and infections. A new evidence-based clinical practice guideline by the American College of Physicians (ACP) found that the harms outweigh the potential benefits, and recommends strongly against screening pelvic examinations in asymptomatic nonpregnant adult women.
The guideline included a systematic review of English-language studies published from 1946 to 2014 to determine the best current evidence for the diagnostic accuracy, benefits, and harms of the screening pelvic examination for detection of cancer, pelvic inflammatory disease, or other benign gynecologic conditions. For cancer detection, across 3 cohort studies with 5,633 asymptomatic women, only 4 cases of ovarian cancer were detected by pelvic examination. And in a randomized trial evaluating screening for ovarian cancer with transvaginal ultrasonography and CA-125 in 78,000 women, the bimanual pelvic examination was dropped after 5 years because no cancer was detected solely by this examination. The ACP is clear in distinguishing the pelvic exam from cervical cancer screening using visual inspection and swabs for cervical cytology, and cervical cancer screening can be completed without a bimanual pelvic examination.
No studies were identified that evaluated the diagnostic accuracy or benefits of pelvic examination for asymptomatic pelvic inflammatory disease, benign conditions, or gynecologic cancer other than cervical or ovarian cancer. Harms identified for the pelvic examination included pain or discomfort reported by 11%-60% in 8 studies with 4,576 women, and fear, embarrassment, or anxiety reported in 10%-80% in 7 studies with 10,702 women. Women experiencing pain or discomfort during their examination were less likely to have a return visit than those not experiencing pain or discomfort in 5 of 5 studies reporting this outcome.
Many aspects of routine care are based on established practice, and have not been subject to rigorous assessment or review. For cancer in particular, there has been a focus in mainstream health messaging that early detection is vital, and many people may not understand that screening carries potential harms that must be weighed against the proposed benefits and may not understand that some of our standard approaches can have little or no efficacy for providing early detection that leads to clinical benefit. This is the first evidence-based guideline evaluating screening pelvic examination in this patient population, and the recommendation against this practice will have an important impact on annual wellness visits for a very large number of women.
For more information see the Ovarian cancer screening topic in DynaMed.