**Transcript of Cyberseminar**

**Spotlight on Evidence-based Synthesis Program**

**Screening Pelvic Examinations in Asymptomatic Average Risk Adult Women: A Systematic Review**

**Presenters: Hanna E. Bloomfield, MD, MPH; Linda Kinsinger, MD, MPH**

**January 23, 2014**

*Moderator:*It looks like we are just at the top of the hour here.  I would like to introduce our presenters for today.  Our first presenter will be Hanna Bloomfield.  Dr. Bloomfield is the director of the Center for Chronic Disease Outcomes Research, the co-chief of the section of general internal medicine and primary care at the Minneapolis VA Medical Center, staff physician in the section of general internal medicine at the Minneapolis VA Medical Center, and a professor of medicine at the University of Minnesota School of Medicine.

Dr. Linda Kinsinger will be joining her.  She is the chief consultant for preventive medicine, Office of Patient Care Services, at the VHA National Center for Health Promotion and Disease Prevention.

They will be joined by Laurie Zephyrin.  Dr. Zephyrin is the national director for reproductive health in the Women Veterans Health Strategic Health Care Group.

With that, I would like to turn things over to Dr. Bloomfield.

*Dr. Bloomfield:*Hi, everybody.  This is Dr. Bloomfield, and so we’ll get started here.  I just want to acknowledge my research team for this project, who are all listed here.  This is a project that came from the Minneapolis Evidence Synthesis Program led by Timothy Wilt.

We’re going to start by—I’m going to start by asking Dr. Kinsinger to explain to us the rationale for the review, since the request form this review came from her office.  Linda?

*Dr. Kinsinger:*Thanks, Dr. Bloomfield.  Thank you very much, and hello to everyone on the call.  My office is responsible for developing clinical preventive service guidance statements.  These are the VHA recommendations on a broad variety of topics related to clinical preventive services including screening tests, and immunizations, and preventive medications, and so on.

As we were about a year and a half ago working on an updated guidance statement or a recommendation about cervical cancer screening, we realized that we weren’t really quite sure about the indications for doing a pelvic exam.  When was that—when should that be done?  When doesn’t it need to be done?

As a part of that whole process, we reached out to the Evidence Synthesis Program to say, “Could you do a review on this topic, and help us learn what’s the evidence—what does the evidence show about the value and the benefits and the harms of doing pelvic exams in women who are asymptomatic for some condition?  Not coming in with lower abdominal pain or some other reason, but as just part of a routine exam.”

That nomination was accepted, and Dr. Bloomfield and her team took it on.  We are very pleased to be the sponsor and supporter of this review.  We think it’ll provide great information for practitioners as they’re providing care for women.

Back to you, Hanna.

*Dr. Bloomfield:*Thank you, Linda.  Today’s presentation is outlined here, and I’m going to start with the objectives and methods of this review.  After discussing the general topic with the internal team and lots of other consultants, we ended up with these three objectives.  To determine for the average-risk, asymptomatic woman the diagnostic accuracy of the pelvic examination for detection of malignancy—we did exclude cervical cancer; we’ll talk about that later—pelvic inflammatory disease or other gynecologic conditions.

The second objective was to determine whether routine screening pelvic examinations—again, not including pap smears—reduce mortality and/or morbidity from any condition.  The third objective was to determine the harms and possible ancillary benefits of the routine screening pelvic exam, because when we talk about an average-risk woman, we’re referring to a woman who by virtue of her family history, her personal history, or her genetic makeup is not at increased risk of gynecologic malignancy.

I think it’s important to realize what is not included in this review.  We do not include pelvic examinations for cervical cancer screening.  Those have been covered by other evidence-based reviews and groups, and I’m going to summarize them at the very end of this talk.  We do not include pelvic examinations for symptomatic women, for women at high risk of gynecologic cancer, as I just mentioned.

We did not review the literature of the value of the pelvic examination for sexually transmitted infection screening because that seems to be commonly accepted that that kind of screening can be done with self-obtained specimens and doesn’t require an actual pelvic examination.  Finally, we did not review the literature about the use of a pelvic examination as a requirement prior to provision of oral contraceptives.  Again, that data seem to be in and commonly accepted that one only needs a blood pressure and medical history prior to prescribing oral contraceptives.

Our literature search is summarized here.  We looked for references in MEDLINE from 1946 through the end of 2013.  We only included English-language publications.  We excluded case series or case reports.  Our search terms included “gynecologic examination,” “women’s health,” and “mass screening.”  We also hand-searched reference lists and used the related citations modality in PubMed to find additional references.

I am now going to show you the results.  Here is the literature flow.  We originally identified 2,349 abstracts and reviewed those.  The vast majority of those we could exclude based on the titles or the abstracts.  We then retrieved 156 articles for full-text review, and two or more members of our research team evaluated each of those articles.  We excluded 143 of them.  We did find an additional 39 articles from the related citations search and from reference lists.  We ended up with 52 papers, and 32 of these included primary data.

I’m going to be presenting the results by the three objectives.  The first objective was to determine the accuracy of the pelvic exam for detection of ovarian cancer and other conditions.  We only found data for ovarian cancer.  Just to remind everybody, the component of the pelvic exam that is used to detect ovarian cancer or ovarian abnormalities in general is the bimanual exam.

We found three studies that evaluated this at least to a certain extent.  These are fairly old studies from the mid-‘90s.  Each of these studies included asymptomatic, average-risk women, middle-aged in general, on average.  Abnormal or ambiguous exams were found in about 1 to 2 percent of patients in the three studies, as you can see listed there.  The one-year incidence of ovarian cancer—these women were all followed for one year clinically, and the one-year incidence is listed there.  Again, very low, 0.04 to 0.1 percent.

From the data available, we were only able to determine a positive predictive value of an abnormal pelvic examination.  Now a positive predictive value means if you get a positive result, in this case if you feel an abnormality on the ovary, what’s the likelihood that that is actually ovarian cancer?  As you can see, the positive predictive value in all three of the studies was very low.

The second objective was to determine whether there were any mortality or morbidity benefits of the screening pelvic examination in this asymptomatic group of women.  We found no studies that assessed the morbidity and mortality benefits.  There are two large contemporary trials of ovarian cancer screening which did not actually use the pelvic examination, specifically the bimanual examination, in their screening protocols because of its low diagnostic accuracy.  I’m going to tell you about those two trials a little later on in the presentation.  Essentially, we came up with nothing for this objective.

The final objective was to determine any harms and possible ancillary benefits of the screening pelvic examination.  The way we categorized harms is shown on this slide.  We categorize them as either psychological harms or indirect harms.  Psychological harms are harms that occur directly related to the pelvic exam, for example, pain, discomfort, fear, anxiety, embarrassment.  The indirect harms are harms that might occur from findings on the pelvic examination.  These include false reassurance, overdiagnosis, overtreatment, and diagnostic procedure-related.  We’ll go over those again in a minute in a little more detail.

To start with, the psychological harms.  We found 15 studies that addressed this issue.  Fourteen of these were survey studies; one was a cohort study.  Nine of these were conducted in the United States.  The median sample size was 409 women, and the range is shown there, 40 to over 7,000.  Unfortunately, the overall quality of these studies was fairly low due to a variety of factors, including the fact that many of them used un-validated survey instruments.  There were low response rates, or response rates were not even reported.  Most of these were not population-based surveys.  That’s the data we have.

These are the findings.  There were eight studies that evaluated the outcomes of pain and discomfort.  It included 4,576 women.  Overall, between 11 to 60 percent of women endorsed pain or discomfort during or in anticipation of the pelvic examination.  The median was 35 percent, so about a third of women endorsed pain or discomfort.  This was more common in younger and nulliparous women, and seemed to be associated with poor compliance with return visits in the five studies that examined that particular outcome.

In terms of embarrassment, fear, and anxiety, this was an outcome in seven of the studies, with a total of 10,000 women.  In these studies, 10 to 80 percent of women endorsed those feelings, and the median was 34 percent.  Again, about a third of women endorsed those feelings during or in anticipation of a pelvic examination.

Indirect harms, first of all, there were no studies that directly addressed these, but I just want to explain what these might be.  The first one is known as false reassurance.  This is the situation in which a woman has a normal pelvic exam, let’s say, then a few weeks or months later gets some kind of symptom that normally she would have evaluated.  But given the fact that she just had a normal pelvic exam she might ignore these symptoms or delay evaluation for these symptoms.  That’s the concept of false reassurance.

The second potential indirect harm was overdiagnosis.  This means that we diagnose an abnormality that actually would never have become clinically manifest, would never have caused the patient any problem.  But we now have labeled this patient, given this patient—or this woman, not really a patient—a diagnosis, and that can have psychological consequences for the person.

Overtreatment refers to treatment that we initiate for one of those overdiagnosed problems.  Again, if we diagnose something that actually would have regressed or never caused problems and then we treat it, that would be considered overtreatment.

Then finally, diagnostic procedure-related harms is self-explanatory.  Like I said, no studies directly addressed any of these, but we do have a little bit of indirect data on this last one, diagnostic procedure-related harm.  One of the studies that was looking at diagnostic accuracy, and that I showed you before, enrolled 2,000 asymptomatic, average-risk women and did screening pelvic examinations on all of them.  They found 174 abnormalities.  Their protocol with an abnormal pelvic examination was to follow up with either a transvaginal or a transabdominal ultrasound, plus or minus a blood test known as cancer antigen 125, which is a marker of ovarian cancer that you can detect in a blood sample.

All of the women who had abnormal screening pelvics then had one or more of these second tests, and based on those ultrasounds or that serum level, 31 of them went to open or a laparoscopic surgery.  This resulted in the diagnosis of two ovarian cancers.  Whether that was overdiagnosis or not, we don’t know.  Whether surgery for those ovarian cancers or treatments resulted in any benefit, we don’t know.  Assuming that it was good to find those two ovarian cancers, we can conclude that 29 out of 2,000 women who were screened, or about 1.5 percent of women screened, with a routine pelvic exam got unnecessary surgery.

Now what’s the disadvantage, so to speak, of surgery?  Well, I think it’s somewhat obvious that people don’t want to undergo surgery if they don’t have to.  In terms of numbers, the risk of major complications in this kind of surgery may be as high as 15 percent, and that’s based on—that’s based on the experience of the PLCO trial, which I’ll be describing a little later.  These 1.5 percent of women then had a risk of major complications that might be as high as 15 percent.

We also looked at psychological harms in subgroups.  We looked for a variety of different subgroups, but the only one in which there was any kind of data really was in women who had a history of sexual violence.  There were nine studies that specifically looked at this population.  Most of these were of low quality.  Eight of them had a control group.  The methodologically strongest one of these was the Behavioral Risk Factor Surveillance Study, known as the BRFSS, and I’ll be showing you that on the next slide.

Here’s a table, though, of all nine studies.  Four studies looked at pain or discomfort in this particular population of women, and there were a total of 1,300 patients, or women, enrolled in those studies.  The results were inconsistent.  Two of the studies reported significantly increased rates of pain and discomfort in women with a history of sexual violence compared to those without, and two of the studies found no difference.  In terms of the outcome—fear, anxiety, embarrassment—there were three studies that looked at that in this group of women with sexual violence.  Only a very small number of women in these studies, a total of 333.  Two of these three studies reported increased rates of fear, anxiety, embarrassment in women with a history of sexual violence compared to those without a history.

Finally, there were five studies with 40,000 patients that evaluated the receipt of gynecologic services, Pap smears in particular, in women with a history of sexual violence.  Again, the data were inconsistent.  Two reported decreased utilization of gynecologic services or Pap smears in women with a history of sexual violence, two reported no difference, and one reported increased utilization.

The methodologically strongest of these studies was the BRFSS, as I said, and this data is probably the best data we have.  It was a population-based telephone survey of a nationally representative United States sample.  It included more than 35,000 women, of whom 15 percent had a history of sexual violence.  The only outcome that was reported that’s relevant to what we’re talking about today was the percent of women reporting having had a Pap smear within the past three years, and this did not differ between the women who had a history and those who did not have a history of sexual violence.  That study did not show that psychological harms of the pelvic examination were any higher in the group of women with a history of sexual violence.

Those are our results.  I’m going to move on now to limitations of our study.  The first limitation is that we limited the evaluation to English-language studies only.  There was a very, very small amount of literature, as you have just seen, on the topic; very few studies on diagnostic accuracy or morbidity/mortality outcomes.  No studies focused on overdiagnosis, overtreatment, or false reassurance.

The psychological harm study, there were a fair amount of studies with several thousand patients enrolled.  The trouble with these studies is that they were almost all of low quality.  They didn’t focus exclusively on asymptomatic women, and it’s possible in this situation that there was selective reporting of positive results.  People who did similar studies to the ones I showed you today who didn’t find any psychological harm may just not have published their studies.  That’s always a possibility in this situation.

Now I’m just going to give you a little bit of context and some implications of these findings.  Ovarian cancer, which is obviously the big elephant in the room, there have been two large contemporary screening trials on this.  One is the PLCO, which was a randomized trial.  Enrolled over 78,000 middle-aged, average-risk women.  Followed them for 12.4 years.

Initially, they did use the bimanual exam as part of their screening protocol, but they dropped it after five years since it was not yielding any results that the other studies were not finding.  Essentially, the screening in this study consisted of serum CA-125, which is that cancer antigen, and transvaginal ultrasonography.

The results with those two screening modalities was that there was increased detection of ovarian cancer in the screening compared to the non-screened population, but there was no decrease in ovarian cancer mortality, unfortunately.  That was reported in JAMA in 2011.

The second large contemporary screening trial is still underway.  It’s due to report in 2015.  This is a study ongoing in England in the U.K.  This at no point included bimanual as part of the screening protocol.

Pelvic inflammatory disease, we did not find any studies that looked at the value of the pelvic examination for detecting pelvic inflammatory disease in asymptomatic women.  Just to remind everybody, this is a syndrome that often presents with vague and minimal symptoms.  It can lead to infertility, ectopic pregnancy, and chronic pelvic pain, so it can be a serious condition.

Current recommendations are that treatment is only initiated when a woman has both symptoms and pelvic exam findings, for example cervical motion tenderness, which can be detected during the pelvic examination.  In order to determine whether a patient needs a bimanual exam to detect cervical motion tenderness, there are symptom questionnaires which can help determine that.  Since sometimes the symptoms are vague and minimal, it often requires a more formal evaluation.

In terms of current practice of providers with respect to performing the pelvic examination, there were some recent surveys done.  One was of 1,250 physicians in the United States, and 54 percent of the internists and 90 percent of the family practitioners and 98 percent of the OB/GYNs stated that they performed the pelvic examination as part of a well woman exam.  Clearly, many, many physicians and providers believe in the pelvic examination in asymptomatic women.

There was another interesting clinical vignette study of 521 OB/GYNs, and 95 percent of them indicated that they would do a bimanual in asymptomatic women who were not due for a Pap smear.  Presumably they were doing this to screen mostly for ovarian cancer, even though there is no evidence of that benefit.

That survey of the OB/GYNs also asked them why they performed routine pelvic examinations.  Here are their answers: 45 percent did so because they believed they were adhering to standard medical practice by performing well woman pelvics, to reassure patients, to detect ovarian cancer—again, about half of the respondents—and finally, to identify the nine conditions.

The cost for a pelvic exam has been said to be about $38.00, and the total annual cost in the U.S. for preventive gynecologic exams with the associated labs and radiology is $2.6 billion.  It’s been estimated that about a third of this total is spent on cervical cancer screening in women under age 21 who by current guidelines do not need to be screened for cervical cancer.  It’s unclear what percentage of this 2.6 billion is spent on other unnecessary exams.  We don’t really know how much unnecessary exams are costing us today.  There’s certainly opportunity cost.  Everybody knows that performing a pelvic examination, especially in a primary care setting as opposed to a gynecologic clinic, requires some hassle: getting the patient set up, getting a chaperone.  It takes time that might have otherwise been spent on other evidence-based activities for that clinic visit.

To conclude, I just again want to remind everybody that we’re not talking about pelvic examinations for cervical cancer screening, for symptomatic women, for women at high risk of gynecologic cancer, for STI screening, or prior to provision of oral contraceptives.  Our conclusions are that we could find no data that a routine pelvic examination in asymptomatic, average-risk women reduces mortality or morbidity from any condition—we did not study cervical cancer, but I’m going to show you that in a minute—and that there was low-quality data that indicate that pelvic examinations may be associated with pain, discomfort, fear, anxiety, and/or embarrassment in about 30 percent of women.

Just to remind you about cervical cancer screening, this requires only a speculum examination, not a bimanual examination, to visualize the cervix and collect the cervical specimen, either for the Pap smear or HPV, as indicated.  It’s not recommended more often than every three years in women under 21, or in women without a cervix, or in women over 65 who have had prior negative exams.  The full recommendations are available at the U.S. Preventive Services Task Force website.  We concluded that one of the major future research directions would be to develop and test strategies to reduce the high rate of inappropriate use of pelvic examinations.

At this point I’m going to turn it over to my colleague, Dr. Zephyrin, who is director of reproductive health in the Office of Patient Care Services.  Glory?

*Dr. Zephyrin:*Yes, thank you.  Thank you, Dr. Bloomfield, for your presentation, and thank you for having me today and presenting this evidence-based review.  I’d like to say that we need to also—we need to keep in mind that women, in terms of providing comprehensive care to women, it involves more than just pelvic exams.

I want to talk a little about our work in women’s health services.  Our goal is to ensure that we’re delivering comprehensive patient-centered care for women, promoting preventive health care and wellness for women, ensuring a safe and healing environment where privacy is paramount, and continuing to enhance quality of care.  In doing that, 100 percent of the VHA health care systems are delivering comprehensive primary care for women veterans, and this comprehensive primary care includes preventive services, acute and chronic illness, coordination of care, gender-specific primary care, and basic mental health care.

At times, these visits may require a pelvic exam, whether it’s for a screening or whether it’s for evaluation of symptomatic complaints.  Even if a patient may not require a pelvic exam at that visit, a comprehensive primary care exam involves other aspects of care such as these preventive services and addressing acute and chronic illnesses and other areas in gender-specific primary care.

Regular visits with primary care providers really is important.  It provides an opportunity to address prevention and well woman care.  In some women, it’s just prevention, wellness, preconception care, reproductive life planning, basic gynecology care.  At those visits, specific symptoms may require further examination by the primary care provider or may require visits for a specialty gynecology or other specialty care.

It’s really, really important to realize that the message here is women still will need to come for comprehensive care and for general health care, which can include the range of primary care, gynecology care, preconception care, birth control evaluation, infertility evaluation and treatment, cancer screenings, mammograms, discussion about wellness and healthy living, nutrition and weight management, smoking cessation, and many other areas.  That’s really very important to keep in mind.

Dr. Bloomfield had mentioned about sometimes pelvic exams, there may be some fear and anxiety that some patients may have.  Some studies have shown that women who may have had prior sexual assault may have increased fear and anxiety or embarrassment.  It’s really important when providing that care to women, if one needs to provide a pelvic exam—all the care should be patient-centered and veteran-centric.  It’s really important to understand some of the patient’s concerns.

Before a pelvic exam, it’s really important to discuss with the patient, before they have disrobed and while they’re sitting up, to ask if there are any problems with or discomfort during prior exams.  Acknowledge that the exam may be stressful, and normalize and validate this.  Reassure her that it’s your goal as the provider to make it as comfortable and least stressful as possible.  It’s important to elicit preferences, what has worked in the past, what has not.  Explain what the examination entails.  Sometimes showing the speculum, how it works, how it sounds, can be helpful.  Reminding the veteran patient that she can terminate the examination at any time, and you can discuss with her direction on how you or she prefer to have this communicated.

It’s really important to have these discussions before the pelvic exam to make it as comfortable an experience as possible, and to really understand and make sure the veteran can understand that she is an active part of this examination.  We want to provide patient-centered care and allow her the opportunity to discuss any concerns she has.

Again, this evidence-based review talks about the evidence around pelvic exams.  Again, the evidence is limited, and sometimes pelvic exams are needed, whether it’s for cervical cancer screening, for symptomatic patients, for STI screening.  What it’s not needed for is, for example, prior to providing a patient with oral contraception.  That shouldn’t be a barrier to providing a patient with oral contraception, for example.

I’d like to turn this back to Dr. Bloomfield.  Thank you.

*Dr. Bloomfield:*Okay, well, that’s the end of our presentation.  I guess that we can accept questions at this point.

*Moderator:*Yes, this is the point where we’re looking for questions from the audience.  Please, this is a great opportunity to ask questions of our panel here.  We are taking questions in writing.  Please use the Q&A screen at the lower right-hand corner of your monitor.  Just type those in, and we’ll get those read out to our presenters today.

*Dr. Kinsinger:*This is Linda Kinsinger.  While we’re waiting for those questions to come in, let me just also remind you that the VHA clinical preventive service guidance statement about cervical cancer screening can be found on our intranet website, which is vaww.prevention.va.gov.  There is also a discussion guide there for providers and patients to use in thinking about who should be screened for cervical cancer, and some very helpful algorithms for following up findings on the cervical cancer screenings.  I encourage you to take a look at that.

*Moderator:*Great.  Thank you, Linda.  We are still waiting for questions to come in.  There we go.  First question that we have: Did you follow up at all on the CA-125 tests?  It seems these are given way more often than is suggested by private specialists.

*Dr. Bloomfield:*No, we did not.  That was out of the scope of what we were reviewing since we were only reviewing the pelvic examination.  I don’t have that—you’re probability absolutely right, knowing in general that tests are over-ordered, especially in the community.  Do any of my co-panelists have any comments on that?

*Dr. Zephyrin:*This is Laurie Zephyrin.  Well, for ovarian cancer screening, the CA-125 test is not the only test that’s used.  There are many other things that can be elevated—can be conditions if CA-125 is elevated.  It can be elevated with endometriosis.  It can be elevated with appendicitis or anything that affects the peritoneum.  It’s really important to use that appropriately and with consultation with a specialist, for example.

*Moderator:*Great.  Thank you.  The next question here: What are VHA guidelines on ovarian cancer screening for asymptomatic women?

*Dr. Kinsinger:*I’ll answer that question.  This is Linda Kinsinger.  We do not have VA-specific guidelines on screening for ovarian cancer yet.  It’s certainly on the list to be developed.  The U.S. Preventive Services Task Force recommendation is to recommend against screening for ovarian cancer, and we would follow that.

*Moderator:*Thank you.  The next question here: I have encountered strong opinions from two VA gynecologists.  This has been addressed—has this been addressed with that group?  This is specifically an issue with routine and not diagnostic exams.

*Dr. Bloomfield:*I don’t know.  I don’t know whether it’s been discussed with those groups.  Hopefully, this will be the beginning of such a discussion.  Linda or Laurie?

*Dr. Kinsinger:*This is Linda.  Let me jump in, and I’ll be eager to see what Laurie has to say as well.  As part of our process for developing our recommendation statements about screening procedures, we send the draft statement out for comment from the field.  As part of that comment process for the cervical cancer screening statement, we did hear similar concerns from a few gynecologists as well.  In fact, it was some of those questions and concerns that got us thinking about what we should say about pelvic exams as part of screening.  I’m certainly aware that there are differences of opinion here.  I don’t know if we’ll ever be able to get everybody on exactly the same page, but we certainly acknowledge that there are differences in how folks look at this situation.

*Dr. Zephyrin:*This is Laurie Zephyrin.  I think it’s important to make the distinction between just a pelvic exam and comprehensive care for women.  This evidence-based review does not say that women do not need to come in for wellness exams, for preconception care, for other visits that they may require.  They will still need to come in for preventive services to ensure wellness and healthy living.  Sometimes they may present with symptoms that may require a pelvic exam based on what Dr. Bloomfield has presented.

There is some controversy, but I think it’s important to understand what the evidence synthesis review says and does not say.  It’s definitely important to ensure that we are still committed to providing comprehensive care to our women veterans.

*Moderator:*Great.  Thank you.  The next question that we have here: Have any studies assessed anxiety created by not doing an annual pelvic exam and strategies for discussing this with patients?

*Dr. Bloomfield:*This is Hanna Bloomfield.  That’s an interesting question.  I do not recall—I don’t recall coming across any studies that address that, although there are certainly some opinion pieces out there that suggest that women expect it, that women want it, or at least have been conditioned to want it.  But I don’t know that I saw any studies that address that.

Other panelists?

*Dr. Kissinger:*I’m not aware of any studies, either, but I haven’t systematically looked.

*Dr. Zephyrin:*I’m not aware of any studies, either.  I also think it’s important to say I am working with the gynecology work group, and we do have a gynecology work group.  Issues that you’ve raised we will continue to address with the work group just to ensure that we’re getting the appropriate message out there.

*Moderator:*Great.  Thank you.  The next question: Are there any options for patients who cannot work with the gynecologist that is available at the VA medical center?

*Dr. Zephyrin:*This is Laurie Zephyrin.  I’m not exactly sure what the question is asking, so if the person that asked can provide a clarification.  But comprehensive care for women is available at all sites.  There are designated women’s health providers at sites that can provide basic gynecology care.  If there is a need for providing more specialized gynecology services, then those services can also be provided, if not on site then possibly through tele-gynecology or through other mechanisms such as non-VA-purchased care.

*Moderator:*Thank you.  We haven’t received clarification in, so I’m not sure exactly if there was any additional information she wanted us to have on that.  Here we go.

*Dr. Bloomfield:*Here we go.  *[Chuckle]*

*Moderator:*The gynecologist is very abrasive and rough.  Perhaps the primary care physician or a nurse practitioner could do the exam.

*Dr. Zephyrin:*I think it is very important to ensure that there is that open communication, as I discussed previously, because that is important for ensuring that the veteran is comfortable during the pelvic exam.  If there are specific issues, feel free to email me—my name is there on the presentation—and we can have an additional discussion to see if we can address your concern.  Thank you.

*Moderator:*Great.  Thank you.  That is all of the questions that we have right now.  We can stall for a minute or two to see if any others are coming in.  While we’re doing that, I wanted to check with our panelists to see if any of you had any follow-up or finishing remarks you would like to make before we close things up today.

*Dr. Bloomfield:*This is Hanna Bloomfield, and I just want to emphasize what Laurie said is that this was a very focused review of the pelvic examination, not of the concept of a well woman visit or a periodic visit to one’s primary care physician to address all the other important issues in health that can be addressed by counseling.  There certainly is some screening that’s evidence-based for women as well as men, so this is not to say—don’t equate any of what we’ve said with that periodic well person visit.  This has to do with the actual performance of the pelvic examination.

*Moderator:*Okay, great.  Thank you.  It looks like we do not have any other questions coming in, so we’re going to wrap up very early today.  For our panelists, Hanna, Laurie, and Linda, I really want to thank all three of you for taking the time to prepare and present for today’s cyber-seminar.  We very much appreciate the time and attention that you have put into this presentation.

For our audience, I want to thank everyone for joining us.  If you can hold on for just another minute or two, I will be putting up a feedback form.  When I close the meeting out, we would very much appreciate your feedback on this session.

As a reminder, we did record today’s session, and I will be sending the link for that out to everyone as soon as that is posted.

Once again, thank you, everyone, for joining us for today’s HSR&D cyber-seminar, and we hope to see you at a future session.  Thank you.

*Dr. Bloomfield:*Thank you.

*[End of Audio]*

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