Screening Pelvic Examinations: The Emperor’s New Clothes, Now in 3 Sizes?

Opinion EDITORIAL Screening Pelvic Examinations The Emperor’s New Clothes, Now in 3 Sizes? George F. Sawaya, MD The US Preventive Services Task Force (USPSTF) has final- ized its recommendation statement 1 regarding periodic screen- ing with the pelvic examination, and it is both unusual and re- markable. It is unusual because the USPSTF typically does not make recommendations about a test separate from a specific health condition. It is remark- able in that it finds the evi- Related articles at jama.com dence insufficient to assess the balance of benefits and harms of performing screening pel- vic examinations in asymptomatic women—a conclusion in di- rect contrast to that of 2 other high-profile professional soci- eties: the American College of Physicians (ACP) and the American Congress of Obstetricians and Gynecologists (ACOG). Evidently, both the ACP and the ACOG believe the evi- dence to be sufficient to make a recommendation, but in dif- ferent directions. The ACP strongly recommends against per- forming the examination in asymptomatic, nonpregnant adult women. 2 This conclusion was based on a systematic review that found no evidence in support of the examination but found evi- dence of harms ranging from psychological distress to unnec- essary surgery. 3 The ACOG, on the other hand, acknowledges the lack of evidence but recommends annual examinations in women 21 years or older “based on expert opinion.” 4(p422) The ACOG’s Well Woman Task Force reinforces the recommenda- tion and the belief that the decision to perform the examina- tion be a shared one between a woman and her clinician. 5 In ef- fect, we now have 3 influential groups making 3 different recommendations. It is important to note that the USPSTF recommendation statement 1 does not apply to health conditions for which the USPSTF already recommends screening, such as cervical can- cer, gonorrhea, or chlamydia in some women. Specifically, the USPSTF addresses the stand-alone value of the routine pelvic examination (which may include any of the following compo- nents, alone or in combination: assessment of the external geni- talia, internal speculum examination, bimanual palpation, and recto-vaginal examination) outside of any other indications. All 3 groups agree on 1 fact: there is a substantial lack of evidence of benefit of the examination in this context, includ- ing its value in screening for ovarian cancer. How can it be that such a long-standing practice has escaped the usual high stan- dards of evidence required of preventive interventions? Has the emperor been traipsing around unclothed for as long as any- one can remember? Perhaps it is the attention to harms that have caused a closer look. The new USPSTF statement 1 puts these harms in sharper focus. In a commissioned evidence report, 6 ovarian jamainternalmedicine.com palpation (a major goal of the bimanual examination) in the setting of ovarian cancer screening was found to yield false- positive rates ranging from 1.2% to 8.6%. In the studies re- viewed, about 5% to 36% of women with abnormal findings on examination ended up having surgery. These observa- tions were made largely among postmenopausal women; abnormal findings on bimanual examination are likely more prevalent among premenopausal women with dynamic ovaries. In the clinical experiences of gynecologists, we have all seen it: the adnexal “fullness” on bimanual examination, the ultrasonogram showing a mass (and the ubiquitous state- ment about the inability to rule out cancer), the repeat ultra- sonogram showing the same, the fear and anxiety, the preop- erative appointment, the surgery, the recovery, the wait for final pathology. The disclosure: “It’s not cancer.” Then, the bill arrives. The physical, psychological, and financial burdens of this sequence of events have not been well described, but like many iatrogenic harms, they lie in a murky, unseen background of low-value care. A back-of-the-envelope analysis suggests that the population harms incurred may be substantial. Over 62 mil- lion pelvic examinations were performed in 2010, 7 and given the ACOG’s recommendation, it can be assumed that many were performed in asymptomatic women. A 2010 survey of US obstetrician-gynecologists indicated that they performed rou- tine examinations of over 85% of women across the patient’s lifespan and even bimanual examination among those women who had undergone total hysterectomy with removal of both tubes and ovaries, 8 indicating that the examination may be more of a ritual than an effective preventive intervention. 9 Many women are also unsure about the purpose of the screening pelvic examination. In a recent study of women re- cruited from women’s clinics, about half did not know the ex- amination’s purpose. 10 Those who claimed to know believed it to be useful mainly in reassurance of normalcy. But is this need for reassurance simply a consequence of decades-long public health messaging about the need for an annual exami- nation? Should we continue to consider the female pelvis a tick- ing time bomb that can only be defused by a clinician at an an- nual visit? How much does such an attitude erode wellness? More importantly, what should clinicians do? The USPSTF believes that in the setting of an “I” statement, clinicians should be forthright with patients about the uncertainty concerning the balance of benefits and harms. Like the ACOG, the USPSTF suggests shared decision making regarding routine pelvic examination. But perhaps the conversation should focus (Reprinted) JAMA Internal Medicine Published online March 7, 2017 Copyright 2017 American Medical Association. 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