U.S. doctors not sure all women need pelvic exams

(Reuters Health) - There isn’t enough evidence to say for sure whether healthy women need routine pelvic screening exams, according to new guidelines from U.S. physicians.

The conclusion issued by the U.S. Preventive Services Task Force (USPSTF) today on pelvic exams comes amid growing debate in the medical community over whether women really need a full pelvic workup every year.

The new guidelines from the government-backed, independent panel of primary care and preventive health experts don’t apply to pregnant women, Pap tests for cervical cancer or checks for certain sexually transmitted infections.

“The USPSTF strongly recommends that women be screened for cervical cancer, so we understand that women will receive a pelvic exam in that circumstance,” said task force member Dr. Maureen Phipps, a women’s health researcher at Brown University in Providence, Rhode Island.

“This new recommendation statement is about whether the pelvic exam by itself is a useful tool to screen for a variety of other gynecologic conditions,” Phipps said by email.

This is the first time the Task Force has weighed in on pelvic exams, which typically involve the insertion of a speculum to widen the vagina and visually examine the cervix as well as a manual internal exam of the reproductive organs and rectum.

Among other things, doctors usually look for yeast infections, genital warts, herpes, pelvic inflammatory disease, fibroids and cysts. They may also check for cancers of the cervix, ovaries or uterus.

Only eight studies since the 1940s have examined the accuracy and harms of pelvic exams, with mixed results, the Task Force writes in JAMA.

Taken together, the available studies don’t conclusively show the accuracy or benefit of the exams for early detection and treatment of many gynecologic problems. It’s also not clear how often women might be harmed by inaccurate “false positive” results that lead to extra tests and unnecessary treatment.

With ovarian cancer, for example, a few studies found false positive results in 1.2 percent to 8.6 percent of cases. Between 5 percent and 36 percent of women with abnormal results suggesting cancer got surgery. Some studies also found “false negative” results that miss malignancies.

Given the scant evidence, the American College of Physicians advises against pelvic exams as part of annual physicals. The American Congress of Obstetricians and Gynecologists, however, recommends pelvic exams as part of annual checkups until women’s age or other health issues make it unlikely they would choose to treat any conditions detected.

Currently, the USPSTF recommends a Pap test every three years for women aged 21 to 29, and every five years for ages 30 to 65. The new pelvic exam guidelines don’t change this advice.

Pap tests can be done without a full pelvic workup, and pelvic exams can occur without a Pap test, Dr. Jeffrey Peipert, author of an accompanying editorial, said by email.

“I do not think all women need an annual pelvic exam,” added Peipert, an obstetrics and gynecology researcher at Indiana University School of Medicine in Indianapolis.

With conflicting guidelines about pelvic exams, doctors should tell patients there’s uncertainty about the value of these screenings and discuss whether they’re needed on case by case basis, Dr. George Sawaya of the University of California, San Francisco, writes in an accompanying editorial in JAMA Internal Medicine.

Women might, for example, need exams when they have unusual pelvic pain, vaginal bleeding or other concerning symptoms, Sawaya argues. But some women without symptoms might not want the invasive exams.

“Prevention is designed to make well people in the present ‘weller’ in the future, and that is difficult,” Sawaya said by email. “This is why we need to have a high standard of evidence for prevention - we don’t want to make well people sick in our pursuit of making them healthier in the future.”

SOURCE: JAMA and JAMA Internal Medicine online March 7, 2017.