Is the annual bimanual exam — that awkward feet-in-the-stirrups moment when the doctor inserts two gloved fingers into your vagina to feel your cervix, uterus and ovaries while pressing down with the other hand on your abdomen — soon to follow?
An increasing number of experts now challenge the value of this time-honored practice, which is done as a matter of course when women come in for routine gynecological checkups or Pap smears.
These experts say that for women who are well, a routine bimanual exam is not supported by medical evidence, increases the costs of medical care and discourages some women, especially adolescents, from seeking needed care.
Moreover, the exam sometimes reveals benign conditions that lead to follow-up procedures, including surgery, that do not improve a woman’s health but instead cause anxiety, lost time from work, potential complications and unnecessary costs.
‘Not supported by research’
Brody describes the specific justifications that gynecologists and other primary care physicians have used to support routine bimanual exams: It helps with the early detection of cervical and ovarian cancer. It serves as a screening tool for chlamydia and other sexually transmitted diseases (STDs). It helps identify benign uterine fibroids. It’s needed to evaluate women before they start taking birth control pills.
But, as Brody explains, those justifications “either do not require a bimanual exam or are not supported by research.”
A large study by the National Cancer Institute, for example, found that bimanual examination alone did not help detect ovarian cancer. Indeed, the NCI now states on its website that “[t]here is no evidence for the benefit of this test for the early detection of and decreased mortality from ovarian cancer.”
And as for detecting STDs, a simple urine or swab test (administered by women themselves) can be used to collect specimens for screening.
For these and other reasons, many other countries do not recommend routine bimanual screening.
“In Sweden, the Netherlands, and the United Kingdom, the bimanual examination is performed only in the evaluation of women with symptoms,” wrote Dr. Carolyn L. Westhoff, a gynecologist at Columbia University Medical Center, in a 2011 paper in The Journal of Women’s Health. “It is not combined with routine cervical screening and is not a part of the periodic examination of asymptomatic women.”
“This practice difference may explain, in part,” she added, “why women in the United Kingdom undergo so much less ovarian cystectomy and hysterectomy than do women in the United States.”
‘An uphill battle’
Getting physicians (and patients) out of the habit of the annual bimanual exam is “likely to be an uphill battle,” writes Brody (as it has been for the annual Pap test). Recent surveys, she notes, “have shown that most gynecologists in the United States consider the routine bimanual exam of internal reproductive organs an important part of a well-woman visit. The practice is endorsed by the American College of Obstetricians and Gynecologists, which nonetheless admits that medical evidence to justify it is lacking.”
“Substantial resources are consumed every year in the simple performance of millions of pelvic examinations in asymptomatic women, even while clinicans lack time to provide other proven preventive services,” wrote Westhoff in her 2011 article. “… Overutilization of services is the most important contributor to the high cost of U.S. Healthcare. Increasingly, we recognize that more services do not always lead to improved health outcomes and that often the opposite is true: that more services are associated with worse health outcomes. The routine pelvic examination may be an example of more service leading to worse outcomes.”
“It is time,” she added, “to get asymptomatic women off the table.”