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No good evidence that routine pelvic exams are beneficial, task force says

No good evidence that routine pelvic exams are beneficial, task force says
REUTERS/Joshua Lott
Dr. Maureen Phipps: “There is not enough evidence to make a determination on screening pelvic exam in asymptomatic women for conditions other than cervical cancer screening, gonorrhea and chlamydia.”

The pelvic exam — a central (and often dreaded) element of a woman’s annual visit with her doctor — offers no proven advantages for healthy women, the U.S. Preventive Services Task Force (USPSTF) announced on Tuesday.

After conducting its first-ever review of the scientific evidence for this common procedure, the task force concluded “the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women.”

This finding adds to the mounting list of long-practiced medical procedures — including screening mammograms and PSA tests for prostrate cancer — that evidence-based reviews are discovering have questionable benefits.

The USPSTF’s recommendation does not apply to screening exams for cervical cancer (Pap tests) and sexually transmitted diseases. Those screenings are “highly” recommended by the task force, but can be done with swabs and other testing methods that don’t require a pelvic exam.

“There is not enough evidence to make a determination on screening pelvic exam in asymptomatic women for conditions other than cervical cancer screening, gonorrhea and chlamydia,” said task force member Dr. Maureen Phipps in a released statement.

“Women with gynecologic symptoms or concerns should discuss them with their clinicians,” she added.

‘Inadequate evidence’

Doctors use pelvic exams to find several gynecologic conditions, such as endometriosis, uterine fibroids, pelvic inflammatory disease, cervical polyps and ovarian cysts. But the USPSTF found “inadequate evidence” to support the claim that finding and treating these conditions before they produce symptoms either saves lives or improves women’s quality of life.

The task force also found “inadequate evidence” that routine pelvic exams cause harm, although they note that a few studies have reported that the exams’ false-positive rates (the percentage of exams that suggest a woman has a medical problem when she doesn’t) might be as high as 46 percent.

The false-positive rates in studies involving ovarian cancer, for example, range from 1.2 percent to 8.6 percent, but the likelihood that the woman actually has the disease is 0 percent to 3.6 percent.

Yet, studies also show that 5 percent to 36 percent of women whose pelvic exam suggested ovarian cancer go on to have surgery.

Another potential harm from routine pelvic exams are “false-negatives” — a finding that suggests a woman does not have a medical condition requiring treatment when she does. Such false reassurance can lead to serious harm, for the woman may subsequently ignore early symptoms of disease, which, in some cases, can be a deadly mistake.

Not the first

The USPSTF is not alone in its interpretation of the evidence regarding routine pelvic exams for healthy women. Both the American College of Physicians and the American Academy of Family Physicians have previously made similar recommendations.

But such statements from the USPSTF — an independent panel of physicians and other experts with backgrounds in prevention and evidence-based medicine — tend to be particularly influential in changing how physicians practice.

In recent years, the value of routine annual physical exams — with or without a pelvic exam — has been called into question. Indeed, as I’ve pointed out here before, the USPSTF has declined to make a recommendation on routine annual health checkups. Canadian guidelines have recommended against these exams since 1979.

Needed: clear answers

The task force notes that 68 percent of U.S. obstetricians-gynecologists routinely perform pelvic exams on their patients, and that more than 60 million of these exams were done in the U.S. in 2010 (the last year, apparently, for which such data is available).

Although the USPSTF does not consider cost when making any of its medical-practice recommendations, the cost of a complete physical exam that includes a pelvic exam averages around $125 in the U.S., according to the Choosing Wisely campaign.

That compares to around $40 without the pelvic exam.

“The Task Force is calling for more research to better understand the benefits and harms of performing screening pelvic exams in women without any complaints or symptoms,” said task force member Dr. Francisco Garcia in the USPSTF’s released statement.

Women are calling for it, too.

FMI: The USPSTF recommendation issued Tuesday is a draft. It has been posted, along with the task force’s review of the evidence, on the group’s website. The task force is asking for public input through July 25, after which it will write its final recommendation.

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