Obstetrician-Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women.

CLINICAL INVESTIGATION Obstetrician–Gynecologist Practices and Beliefs Regarding External Genitalia Inspection and Speculum Examinations in Healthy Older Asymptomatic Women Amy Hsu, MD,* Jillian T. Henderson, PhD, MPH, † Cynthia C. Harper, PhD, ‡ and George F. Sawaya, MD ‡ OBJECTIVES: To understand obstetrician–gynecologist perceptions of the value of external genitalia inspection and speculum examinations in older and younger healthy women across the life span. DESIGN: National survey from May 2010 to January 2011 asking obstetrician–gynecologists about the need for and importance of external inspection and speculum exam- ination in four scenarios of asymptomatic healthy women aged 70, 55, 35, and 18 who present for routine health visits. Separate questions asked about the importance of various reasons for these examinations. SETTING: Mail-in survey of a national sample of obste- trician–gynecologists. PARTICIPANTS: Probability sample of obstetrician–gyne- cologists from the American Medical Association Physician Masterfile (N = 521). MEASUREMENTS: Proportion of obstetrician–gynecolo- gists who would perform external inspection and speculum examinations and consider these examinations to be very important. RESULTS: The response rate was 62%. In a healthy 70- year-old woman, 98% of respondents would perform external inspection, and 86% would perform a speculum examination. Ninety percent would perform a speculum examination in a healthy 55-year-old woman after removal of her uterus, cervix, and ovaries. Respondents more often indicated that the external examination was very impor- tant in the 70-year-old (63%) than in younger women (46–53%). Reasons rated as very important included iden- tifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care. From the *Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California; † Kaiser Permanente Center for Health Research, Portland, Oregon; and ‡ Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, California. Address correspondence to Amy Hsu, Division of Geriatrics, VA Medical Center, 4150 Clement Street, 181G, San Francisco, CA 94121. E-mail: amy.hsu@ucsf.edu DOI: 10.1111/jgs.13954 JAGS 2016 © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society CONCLUSION: Obstetrician–gynecologists would com- monly perform external and speculum examinations in asymptomatic women and believe the external examina- tion to be particularly important in older women for can- cer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care. J Am Geriatr Soc 2016. Key words: obstetrics-gynocology; pelvic exam; asymp- tomatic; women. A pproximately 62.8 million pelvic examinations were performed in the United States in 2010. 1 Current rec- ommendations regarding the appropriateness of pelvic examinations in asymptomatic older women are inconsis- tent. In August 2012, the American College of Obstetri- cians and Gynecologists (ACOG) issued a Committee Opinion (reaffirmed in 2014) stating that it would be rea- sonable to stop performing pelvic examinations when a woman’s age or other health concerns reached a point at which she would not choose to intervene on conditions detected during the routine examination. 2 Women who have undergone a total hysterectomy and bilateral salp- ingo–oophorectomy for noncancer diagnoses and are asymptomatic should continue external examination but can decide whether to receive an internal examination. ACOG acknowledged that no evidence supports or refutes performing an annual pelvic examination in asymptomatic, low-risk women. In contrast, the American College of Physicians (ACP) recommends against performing screen- ing pelvic examinations in asymptomatic, nonpregnant women based on a systematic review that reported lack of benefit and potential for harm. 3 Despite the lack of evi- dence for performing pelvic examinations in older women who are asymptomatic and in women who have undergone total hysterectomy and bilateral salpingo–oophorectomy, many physicians continue to perform screening pelvic examinations in these women.