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    Whither the annual bimanual pelvic examination?

    The absence of evidence for benefit is not the same as evidence of absence of benefit.

     


     

    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa. He can be reached at [email protected]

     

     

    Recently, Qaseem and colleagues published an American College of Physicians (ACP) Clinical Guideline advising against pelvic examinations for the detection of pathological conditions in asymptomatic, nonpregnant, adult women.1

    This advisory has generated much commentary in the blogosphere and particularly among ob/gyns. Many women, upon hearing news reports concerning the ACP guidelines, will assume these recommendations are valid and that they no longer need annual pelvic exams. Moreover, some women may assume that since they no longer need such an exam, they also will not need to see their gynecologist annually.

    When added to the confusion already rampant as to the need for mammograms and Pap smears, this ACP guideline will add yet another barrier to our ability to provide appropriate preventative care to our patients.

    Are screening pelvic exams needed?

    The Qaseem et al. study was a literature review conducted by the Minneapolis Veterans Affairs Health Care System’s Evidenced-based Synthesis Program center. The authors sought to assess the accuracy, benefits, and harms of screening pelvic examinations. They defined a pelvic exam as a “combination” of speculum and bimanual examination not including cervical cancer screening.

    For this purpose, the authors conducted a MEDLINE search of relevant articles addressing these questions published from 1946 to 2014. Based on their findings, the ACP strongly recommended “against performing screening pelvic examinations in asymptomatic, non-pregnant, adult women” based on “moderate-quality evidence.” Potential harms cited included unnecessary laparoscopies or laparotomies, fear, embarrassment, anxiety, pain or discomfort and, ironically, avoidance of necessary care.

    While I do believe there is a place for evidence-based medicine and I strongly support thoughtful, comprehensive, and data-rich analyses whose conclusions have robust statistical support, this study had none of those elements.

    First the authors focused only on ovarian cancer and detection of bacterial vaginosis because those were the only conditions about which there were sufficient published data to draw tangential conclusions. (What is the old line about the inebriated fellow looking for his keys under the lamp post because that is where the light is shining?) As such, the authors failed to address the myriad of other reasons ob/gyns carry out bimanual exams, such as for detection of myomas, evidence of pelvic relaxation and stress incontinence, signs of endometriosis, chronic pelvic inflammatory disease, cervical polyps, vaginal cysts, etc.

    Indeed the authors report that no studies directly address the utility of pelvic exams for any of these conditions. They also note that no studies have evaluated the potential indirect benefit of annual pelvic exams on non-ovarian and non-cervical cancer morbidity or mortality. Furthermore, they point out that no studies have evaluated the potential benefit of such exams as an incentive for women to access care and receive “recommended gynecological services, such as contraception, screening for sexually transmitted infections and other nongynecologcial care.”

     

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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      An important perspective on a critical topic from a leader in the field.

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