Screening Pelvic Examinations (PE) in 

Asymptomatic Average Risk Women 

A Systematic Review of the Evidence 

Hanna E. Bloomfield, MD, MPH 

January 23, 2014
Research Team

Andrew Olson, MD

Nancy Greer, PhD

Amy Cantor, MD, MHS

Roderick MacDonald, MS

Indulis Rutks, BA

ESP Director: Timothy J. Wilt, MD, MPH
Rationale for Review 

Linda Kinsinger, MD, MPH 

Chief Consultant for Preventive Medicine at VHA 

National Center for Health Promotion and Disease 

Prevention
Today’s Presentation

• Objectives and Methods 

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment
Objectives 

To determine for average risk* asymptomatic women:

1.The diagnostic accuracy of the PE for the detection of 

malignancy (other than cervical), pelvic inflammatory disease, or 

other gynecologic conditions

2.Whether routine screening PEs (not PAP smears) reduce 

mortality and/or morbidity from any condition

3.The harms and ancillary benefits of the routine screening PE

Full report at http://www.hsrd.research.va.gov/publications/esp/

* not at increased risk of gynecologic malignancy, by history or genes
What is NOT included

Pelvic examinations...

– For cervical cancer screening (see USPTF guidelines)

– For symptomatic women

– For women at high risk of gynecologic cancer

– For STI screening (can be done with self obtained specimens)

– Prior to provision of OCPs (need only BP and medical history)
Literature Search

• MEDLINE 19462013 

• English language only

• Excluded case series or case reports

• Search terms: Gynecologic Examination, 

Women’s Health, and Mass Screening 

• “Related Citations” and hand searching of 

reference lists
Today’s Presentation

• Objectives and Methods

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment
Literature Flow

2349 abstracts from 

MEDLINE reviewed

2193 abstracts excluded

156 articles retrieved for 

full-text review

143 articles excluded at full-text review

39 articles from related citations & 

reference lists 

52 included papers

32 with primary data
Objective 1: Accuracy of Pelvic Exam (PE) 

for detection of ovarian cancer

Bimanual examination is the component of the 

PE used to detect ovarian abnormalities

Reference Population

Abnormal or 

ambiguous 

exams

1 year incidence 

of ovarian cancer

Positive 

predictive 

value** of an 

abnormal PE

Adonakis 

1996 

N=2000 

Mean age 58 174 (.09%) 2/2000 (0.1%) 1.2% (2/174) 

Grover 

1995 

N=2623 

Mean age 51 40 (1.5%) 1/2623* (0.04%) 0% (0/40) 

Jacobs 

1998 

N=1010 

Median age 54 28 (2.7%) 1/1010 (0.1%) 3.6% (1/28) 

* The single case occurred in a woman with a normal PE 

** Positive Predictive Value: true positives / all positives
Objective 2: Mortality and 

Morbidity Benefits

• No studies assessing the morbidity and 

mortality benefits of routine PEs in 

asymptomatic women for any condition

• The 2 large contemporary trials of ovarian 

cancer screening did not use the bimanual 

examination in their screening protocols 

because of its low diagnostic accuracy
Objective 3: Harms

• Potential Harms

– Psychological harms of the exam: pain, 

discomfort, fear, anxiety, embarrassment

– Indirect harms: false reassurance, over-diagnosis, 

over-treatment, diagnostic procedure related
Psychological Harms

Fear, Anxiety, Embarrassment, Pain, Discomfort

• 15 studies (14 surveys, 1 cohort)

• 9 in US

• Median sample size: 409 (40 to 7168)

• Overall study quality: Low

– Un-validated surveys

– Low response rates

– Not population based
Psychological Harms

Fear, Anxiety, Embarrassment, Pain, Discomfort

• Pain/discomfort (8 studies, N=4576) 

– 11-60% (median 35%)

– More common in younger, nulliparous women

– Associated with poorer compliance with return visits 

in all 5 studies that examined the issue

• Embarrassment/fear/anxiety (7 studies, N=10,702)

– 10-80% (median 34%) 
Indirect Harms 

 

 

•False reassurance

– Normal PE  pt ignores/delays evaluation for new symptoms

•Over-diagnosis

– Diagnosis of an abnormality that would never have become 

clinically manifest

– Psychological consequences

•Over-treatment

– Treatment initiated for an abnormality that would have 

regressed or never caused problems

•Diagnostic procedure-related harms

•No studies directly addressed these
Indirect Harms 

Diagnostic Procedure-related 

174 abnormal screening PE’s in 2000 asymptomatic 

average risk women

174 Transvaginal US or 

Transabdominal US + CA-125 

Adonakis et al Eur J Obstet Gynecol Reprod Biol 1996;65:221 

31 women

went to open or laparoscopic surgery

2 ovarian cancers

29/2000 (1.5%) of women having a 

routine PE get

unnecessary surgery
Indirect Harms 

Diagnostic Procedure-related 

 

Buys JAMA 2011;305:2295 

29/2000 (1.5%) of women having a 

routine PE get

unnecessary surgery

Risk of major 

complications may 

be as high as 15%
Psychological Harms in Subgroups:

Sexual Violence (SV) 

Outcome

# of 

studies

Results for women with h/o SV 

(c/w women without h/o SV) 

Pain/ 

Discomfort 

4 

N=1344 Inconsistent: 2 reported significantly increased 

rates*, 2 no difference 

Fear/Anxiety/ 

Embarrassment 

3 

N=333 2/3 reported increased rates* 

Receipt of Gyn 

Services/Paps 

5 

N=40,007 

Inconsistent: 2 reported decreased utilization*; 2 

(including BRFSS) reported no difference; 

1 reported increased utilization*

• 9 studies, most of low quality, 8 with a control group

• Methodologically strongest Behavior Risk Factor 

 Surveillance Study (BRFSS)

This table includes the 8 studies with control groups; * p <0.05 
Psychological Harms in Subgroups:

Sexual Violence 

• Methodologically strongest BRFSS

• population-based

• telephone survey

• nationally representative US sample

• 35,000+ women, 15 % w/ h/o SV

• Outcome: % reporting PAP w/in past 3 yrs

– Did not differ between SV+ and SV- groups
Today’s Presentation

• Objectives and Methods

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment
Limitations 

• English language only

• Paucity of literature

– Few studies on diagnostic accuracy or 

morbidity/mortality outcomes

– No studies focused on over-diagnosis, over 

treatment, false reassurance

• Psychological Harms studies 

– Low quality

– Did not focus exclusively on asymptomatic women

– Selective reporting of “positive” results?
Today’s Presentation

• Objectives and Methods 

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment
Ovarian Cancer 

• 2 large contemporary screening trials

• PLCO (Buys et al JAMA 2011;305:2295)

– RCT, N > 78,000, 12.4 yrs f/u

– Bimanual exam dropped after 5 years

– Serum CA-125, T-V ultrasonography

• Increased detection of ovarian cancer

• No decrease in OC mortality

• UK-CTOCS (Menon et al Lancet Oncol 2009;10:327)

– Did not include bimanual

– Due to report in 2015
Pelvic Inflammatory Disease

• Often presents with vague/minimal symptoms

• Can lead to infertility, ectopic pregnancy, 

chronic pelvic pain

• CDC recommends treatment only when a 

woman has both

– Symptoms 

– PE findings (eg cervical motion tenderness)

• Symptom questionnaires can help determine 

which patients need a bi-manual (Fisher et al Clin Pediatr 

2004;43:153)
Current Practice

• Survey of 1250 US MDs (Stormo Arch Intern Med 2011 & Prev Med 2012)

– Perform PE as part of a well-woman exam 

• 54% internists

• 90% FPs

• 98% OB-GYNs

• Clinical Vignette, 521 ob-gyns (Henderson Am J Ob Gyn 2013)

– 95% would do a bi-manual in asymptomatic women 

not due for a Pap
Reasons for Performing 

Routine PEs

Survey of 521 US Ob-Gyns

•Adherence to Standard Medical Practice (45%)

•Patient Reassurance (49%)

•Detection of Ovarian Cancer (47%)

•Identification of Benign Conditions (54-59%)

Henderson Am J Ob Gyn 2013 
Cost

• $38 for the exam

• Total annual cost in US for preventive 

gynecologic exams and associated 

labs/radiology: $2.6 billion

– 1/3 on cervical cancer screening in women under 

age 21

– ?? % on other unnecessary exams

• Opportunity Costs

Mehrota et al Arch Intern Med 2007;167:1876 

Morioka-Douglas et al JAMA Intern Med 2013;173:855 
Today’s Presentation

• Objectives and Methods 

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment
What was NOT included

Pelvic examinations...

– For cervical cancer screening (see USPTF guidelines)

– For symptomatic women

– For women at high risk of gynecologic cancer

– For STI screening (can be done with self obtained specimens)

– Prior to provision of OCPs (need only BP and medical history)
Conclusions 

• No data that a routine PE in asymptomatic 

average risk women reduces mortality or 

morbidity from any condition, other than 

cervical cancer

• Low quality data indicate that PEs may be 

associated with pain, discomfort, fear, anxiety, 

and/or embarrassment in about 30% of 

women
Cervical Cancer Screening

• Requires only speculum exam for visualization 

of cervix and collection of cervical specimen 

(for Pap, papilloma virus)

• Is not recommended

• more often than every 3 years

• in women under 21 or without a cervix

• in women over 65 w/ prior negative exams

• Full recommendations available at 

http://www.uspreventiveservicestaskforce.org/uspstf/uspscerv.htm 
Future Research Directions

• Development and testing of strategies to 

reduce the high rate of inappropriate use of 

PEs
Today’s Presentation

• Objectives and Methods 

• Results

• Limitations

• Context and Implications

• Conclusions

• Comment 

Laurie Zephyrin, MD,MPH,MBA,FACOG

Director, Reproductive Health, Office of Patient Care Services
Laurie C. Zephyrin MD, MPH, MBA, FACOG

Director, Reproductive Health

Women's Health Services

Office of Patient Care Services, Veterans Health Administration (VHA)

Department of Veterans Affairs (VA)

January 23, 2014
VETERANS HEALTH ADMINISTRATION

Women’s Health Services

5/2013 2 

• Deliver comprehensive, patientcentered care for women

• Promote preventive health care and 

wellness for women

• Ensure a safe and healing environment 

in which privacy is paramount

• Continue to enhance quality of care
VETERANS HEALTH ADMINISTRATION

2/2013 3 

Comprehensive Primary Care: 

Preventive 

Services

Acute and 

Chronic 

Illness

Coordination 

of Care

Genderspecific 

Primary 

Care 

Basic Mental 

Health Care

• Enhancement of comprehensive care 

– 100% of VHA healthcare system delivering comprehensive 

primary care for women Veterans

Women’s Health Services
VETERANS HEALTH ADMINISTRATION

Comprehensive Women’s Health

• Regular visits with primary care provider provides 

opportunity to address prevention and well woman 

care

– Prevention

– Preconception Care

– Reproductive Life Planning

– Basic Gynecology

• Specific symptoms may require further examination

– May require visits for specialty gynecology or other 

specialty care
VETERANS HEALTH ADMINISTRATION

Pre-Pelvic Exam

• Before the patient has disrobed, while sitting up:

– Ask if any problems with or discomfort during prior exams

– Acknowledge exam may be stressful- normalize, validate 

– Reassure her it is your goal to make as comfortable and “least 

stressful” as possible

– Elicit preferences (what has worked for her in the past, what has 

not)

– Explain what the examination entails (e.g., show speculum, how 

it works/sounds)

– Remind her she can terminate the examination at any time (give 

her direction on how you prefer to have this communicated)