American College of Physicians Issues Guideline Recommending Against Routine Pelvic Exams for Asymptomatic Women
A new evidence-based clinical practice guideline from the American College of Physicians (ACP) is recommending that physicians should not offer routine pelvic examinations to asymptomatic, average-risk, nonpregnant women. The recommendation stems from a review of 52 published articles from 1946 through January 2014 that found little evidence to support routine pelvic exams for average-risk women with no gynecologic symptoms. The review evaluated outcomes, including morbidity; mortality; and harms such as overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort. The guideline is published in the Annals of Internal Medicine.
While pelvic examination is commonly used in asymptomatic women to screen for pathology, the ACP found that the diagnostic accuracy of pelvic examination for detecting ovarian cancer or bacterial vaginosis is low. The new guideline does not apply to Pap smear screening, only to pelvic examination.
The guideline does not address women who are due for cervical cancer screening. “However, the recommended cervical cancer screening examination should be limited to visual inspection of the cervix and cervical swabs for cancer and human papillomavirus and should not entail a full pelvic examination,” according to the guideline.
The ACP advises that the pelvic examination is appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.
Promoting High-Value Care
According to the guideline, despite no evidence showing that screening pelvic exams in asymptomatic, nonpregnant women provides any benefit and indirect evidence that it does not reduce morbidity or mortality rates, many clinicians include the examination as part of the well-woman visit. “Because pelvic examination is low-value care, it should be omitted from the well-woman visit,” states the guideline. The guideline also advises against screening pelvic exams before prescribing hormonal contraception for healthy, asymptomatic women and promotes the use of high-value care to improve health and eliminate wasteful practices.
“With the available evidence, we conclude that screening pelvic examination exposes women to unnecessary and avoidable harms with no benefit (reduced mortality or morbidity rates). In addition, these examinations add unnecessary costs to the health-care system ($2.6 billion in the United States). These costs may be amplified by expenses incurred by additional follow-up tests, including follow-up tests as a result of false-positive screening results; increased medical visits; and costs of keeping or obtaining health insurance,” said the study authors.
Amir Qaseem, MD, PhD, MHA, of the American College of Physicians, is the corresponding author for the Annals of Internal Medicine article.
The development of the guideline was funded by the American College of Physicians. Michael J. Barry, MD, reported grants and other remuneration from Informed Decisions Foundation and Healthwise.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
