Systematic Review Evaluates Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
BACKGROUND:
Many women and providers believe that the routine pelvic exam should be included in an annual comprehensive well-woman visit and a pelvic exam is necessary to do a Pap test or screen for sexually transmitted diseases (STDs) such as chlamydia. Because recent recommendations have suggested that annual Pap testing is not necessary for average-risk women, questions have been raised about whether pelvic exams provide additional benefits in asymptomatic women who do not need a Pap test or STD screening. Traditionally, the examination has been used to screen for pathology through palpation, visualization, and specimen collection, and includes inspection of the external genitalia, speculum examination of the vagina and cervix, bimanual examination (manual examination of both abdomen and vagina), and sometimes rectal or rectovaginal examination. This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. The review did not address pelvic examinations for women with symptoms or at higher than average risk of gynecologic malignancies, based on genetic testing or personal or family history. Investigators reviewed the literature from 1946 through January 2014. Of the 52 studies included in this review, 32 included primary data and 20 were guidelines or other reviews.
FINDINGS:
- No data support the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition.
- The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% (8 studies; n=4,576). The percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80% (7 studies; n=10,702).
- No studies assessed the morbidity or mortality benefits of the bimanual examination as a screening test for ovarian cancer in asymptomatic average-risk women, and most major professional and government groups recommend against such screening. In addition, no studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
LIMITATIONS:
- The literature used in this review had substantial methodological weaknesses, including unrepresentative populations, low response rates, and inadequately validated survey instruments.
- There were few studies that addressed the diagnostic accuracy or the morbidity or mortality benefits of the pelvic examination in asymptomatic women.
- Studies reporting psychological harms were generally of low quality.
NOTE: The full evidence report was prepared by HSR&D's Evidence-Based Synthesis Program (ESP) and is available on the HSR&D website (Intranet only).
AUTHOR/FUNDING INFORMATION:
This study was funded by VA/HSR&D's Quality Enhancement Research Initiative (QUERI). Drs. Bloomfield, Greer, and Wilt are part of HSR&D's Center for Chronic Disease Outcomes Research in Minneapolis, MN.
Bloomfield H, Olson A, Greer N, Rutks I, Cantor A, MacDonald R, and Wilt T. Screening Pelvic Examinations in Asymptomatic Average-Risk Adult Women: An Evidence Report for a Clinical Practice Guideline for the American College of Physicians. Annals of Internal Medicine. July 1, 2014;161(1):46-53.
