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Research Letters |

The Pelvic Examination as a Screening Tool FREE

Analía R. Stormo, BS; Nikki A. Hawkins, PhD; Crystale Purvis Cooper, PhD; Mona Saraiya, MD, MPH
[+] Author Affiliations

Author Affiliations: Division of Cancer Prevention and Control, CDC, Atlanta, Georgia (Ms Stormo and Drs Hawkins and Saraiya); and Soltera Center for Cancer Prevention and Control Research, Tucson, Arizona (Dr Cooper).


Arch Intern Med. 2011;171(22):2053-2054. doi:10.1001/archinternmed.2011.575.
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According to the Centers for Disease Control and Prevention (CDC), approximately 63.4 million pelvic examinations were performed in US physicians' offices and US clinics in 2008.1 Traditionally, this procedure has been performed in conjunction with annual Papanicolaou tests but since the American College of Obstetricians and Gynecologists extended its recommended cervical cancer screening interval to no more than every 3 years with human papillomavirus co-testing,2 there are questions about whether an annual pelvic examination is needed.

Pelvic examinations have been performed on asymptomatic women to screen for sexually transmitted infections, to screen for ovarian and other gynecologic cancers, and to determine whether women should receive hormonal contraceptives. However, use of pelvic examinations for these purposes is not supported by scientific evidence and is not recommended by any US organization.36

Little is known about physicians' pelvic examination practices. In a recent Australian study, reasons general practitioners gave for performing pelvic examinations of asymptomatic women ranged from detecting pathologic conditions to simply performing this procedure “out of habit.”7 In this study, we sought to determine the purposes for which US physicians conduct pelvic examinations.

We analyzed data collected from internists, family/general practitioners (FP/GPs), and obstetrician/gynecologists (OB/GYNs) who participated in the 2009 DocStyles survey of US physicians. Because personal identifiers were not included in the data set, institutional review board approval was not required. Sampling quotas for the 2009 DocStyles survey were 1000 primary care physicians (internists and FP/GPs combined) and 250 OB/GYNs. In July 2009, e-mail invitations to take part in the survey were sent to 2325 internists or FP/GPs and 500 OB/GYNs, who were randomly selected from the Epocrates Honors Panel (156 000 US physicians) to match the proportion of physicians in the American Medical Association Physician Masterfile by age, sex, and region. Survey responses were obtained from 391 internists, 609 FP/GPs, and 250 OB/GYNs who met the following 2009 DocStyles survey inclusion criteria: practiced in the United States; treated at least 10 patients a week; worked in an individual or group practice, hospital, or clinic; and had practiced medicine for at least 3 years.

Participants were asked how often they performed the pelvic examination “as part of a well-woman exam,” “to screen for ovarian cancer,” “to screen for other gynecologic cancers,” “to screen for STIs [sexually transmitted infections],” and “as a requirement for starting oral or other hormonal contraception.” Response options were “always,” “most of the time,” “some of the time,” “rarely,” and “never.” In our analyses, we defined “routine use” as “always” or “most of the time.”

The mean (SD) age of participants was 45.3 (9.1) years and most were male (70.2%), white (74.3%), and worked in a group practice (63.4%). All pelvic examination practices studied differed by specialty (P < .001), with most OB/GYNS (71.6%-98.4%) and FP/GPs (55.2%-89.5%) reporting that they routinely perform pelvic examinations for each of the stated purposes and the minority of internists (29.7%-41.2%) reporting routine use of pelvic examinations for these purposes with the exception of “as part of a well-woman exam” (54.0%) (Table).

Table Graphic Jump LocationTable. Physicians Reporting Routine Use of Pelvic Examinations for Selected Purposes, by Specialty (DocStyles Survey, 2009)a

Current American College of Obstetricians and Gynecologists guidelines on cervical cancer screening2 represent a paradigm shift in clinical practice: not only is the Papanicolaou test no longer recommended on an annual basis, but the need for the pelvic examination has been called into question. Most physicians across specialties reported routinely performing pelvic examinations as part of well-woman exams; however, the conditions pelvic examinations hope to detect during these annual visits are unclear, since scientific evidence does not support their use for any specific purpose.

Most FP/GPs and OB/GYNs reported performing pelvic examinations to routinely screen for sexually transmitted infections and as a requirement for the prescription of hormonal contraception, for which a pelvic examination is not recommended. This is concerning because the invasive nature of pelvic examinations may deter some women from using hormonal contraceptives and those who are 25 years or younger from being routinely screened for Chlamydia.3,5

The accuracy of pelvic examinations for the early detection of ovarian cancer is poor and no US organization endorses using them for cancer screening,3,4 yet our findings suggest that pelvic examinations are still routinely performed for this purpose, especially by OB/GYNs. The high percentage of OB/GYNs who continue to use pelvic examinations to screen average-risk women for ovarian cancer is particular cause for concern, given that an estimated 98% of positive screening results among such women are false positives.8 More effective dissemination of guidelines for ovarian cancer screening and emphasis on the harmful consequences of false-positive findings, including overtesting and undue anxiety, may be useful in addressing the misuse of pelvic examinations to screen for this type of cancer.

Pelvic examination practices among US physicians are not evidence based. Increased education efforts are needed to emphasize the limitations and harms associated with the use of pelvic examinations.

Correspondence: Dr Saraiya, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail Stop K-55, Atlanta, GA 30341 (msaraiya@cdc.gov).

Author Contributions: Ms Stormo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Stormo, Hawkins, Cooper, and Saraiya. Acquisition of data: Cooper. Analysis and interpretation of data: Stormo, Hawkins, Cooper, and Saraiya. Drafting of the manuscript: Stormo and Hawkins. Critical revision of the manuscript for important intellectual content: Stormo, Hawkins, Cooper, and Saraiya. Statistical analysis: Stormo, Hawkins, and Cooper. Study supervision: Cooper and Saraiya.

Financial Disclosure: None reported.

Funding/Support: This research was supported in part by an appointment to CDC's Research Participation Program administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and CDC.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

Additional Contributions: Cynthia Gelb, BSJ, and Lindsey Polonec, BA, MA, reviewed an earlier version of the manuscript. The data reported in this study were gathered by CDC's Division of Cancer Prevention and Control to inform development of its Inside Knowledge: Get the Facts About Gynecologic Cancer campaign (http://www.cdc.gov/cancer/knowledge/).

This article was corrected for an error in text on December 19, 2011.

Centers for Disease Control and Prevention.  National Ambulatory Medical Care Survey: 2008 summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/namcssum2008.pdf. Accessed March 2, 2011
ACOG Committee on Practice Bulletins—Gynecology.  ACOG Practice Bulletin No. 109: cervical cytology screening.  Obstet Gynecol. 2009;114(6):1409-1420
PubMed
Westhoff CL, Jones HE, Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete?  J Womens Health (Larchmt). 2011;20(1):5-10
PubMed   |  Link to Article
Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening.  CA Cancer J Clin. 2009;59(1):27-41
PubMed   |  Link to Article
Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs evidence.  JAMA. 2001;285(17):2232-2239
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  CDC Grand Rounds: chlamydia prevention: challenges and strategies for reducing disease burden and sequelae.  MMWR Morb Mortal Wkly Rep. 2011;60(12):370-373
PubMed
Stewart RA, Thistlethwaite J, Evans R. Pelvic examination of asymptomatic women—attitudes and clinical practice.  Aust Fam Physician. 2008;37(6):493-496
PubMed
US Preventive Services Task Force.  Screening for ovarian cancer: recommendation statement.  Ann Fam Med. 2004;2(3):260-262
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable. Physicians Reporting Routine Use of Pelvic Examinations for Selected Purposes, by Specialty (DocStyles Survey, 2009)a

References

Centers for Disease Control and Prevention.  National Ambulatory Medical Care Survey: 2008 summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/namcssum2008.pdf. Accessed March 2, 2011
ACOG Committee on Practice Bulletins—Gynecology.  ACOG Practice Bulletin No. 109: cervical cytology screening.  Obstet Gynecol. 2009;114(6):1409-1420
PubMed
Westhoff CL, Jones HE, Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete?  J Womens Health (Larchmt). 2011;20(1):5-10
PubMed   |  Link to Article
Smith RA, Cokkinides V, Brawley OW. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening.  CA Cancer J Clin. 2009;59(1):27-41
PubMed   |  Link to Article
Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs evidence.  JAMA. 2001;285(17):2232-2239
PubMed   |  Link to Article
Centers for Disease Control and Prevention (CDC).  CDC Grand Rounds: chlamydia prevention: challenges and strategies for reducing disease burden and sequelae.  MMWR Morb Mortal Wkly Rep. 2011;60(12):370-373
PubMed
Stewart RA, Thistlethwaite J, Evans R. Pelvic examination of asymptomatic women—attitudes and clinical practice.  Aust Fam Physician. 2008;37(6):493-496
PubMed
US Preventive Services Task Force.  Screening for ovarian cancer: recommendation statement.  Ann Fam Med. 2004;2(3):260-262
PubMed   |  Link to Article

Correspondence

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Submit a Comment
A narrow view of a problem can lead to narrow conclusions
Posted on December 21, 2011
Luis Velez, MD, PhD
UT MD Anderson Cancer Center
Conflict of Interest: None Declared
I am concerned that this research letter is to some degree misleading. First, the analysis of pelvic exams is too narrow. Pelvic exams are not good practice for the detection of ovarian cancer. But the fact that many doctors still believe it is does not negate in any way the utility of pelvic exams for the detection of other reproductive tract problems. If many doctors do it for the wrong reason, what is wrong is the 'reason', not the usefulness of the exam as part of a well-woman visit.
Secondly, the article does not take into consideration the fact that minority, uninsured, poor, overweight, and disabled women often see their doctor only when they feel really sick. Avoiding a pelvic exam in these patients is no doubt a missed opportunity to detect important problems; perhaps not an ovarian cancer, but surely other diseases.
It might be considered old school when doctors were supposed to thoroughly examine their patients. But too much research is done on how to use diagnostic aids and not on how to use medical semiology to guide diagnostic suspicion and to re-humanize medicine. By further eliminating detailed use of their senses in the evaluation of patients, doctors risk soon being totally replaced by automated mechanisms that can process more efficiently the overwhelming amount of lab information that now guides medical practice, while at the same time continue raising health care costs beyond the already absurd levels of today.

Conflict of Interest: None declared
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