ACP’s new guideline suggests a major change in clinical practice.
Annals of Internal Medicine
In a new evidence-based clinical practice guideline being published in Annals of Internal Medicine, the American College of Physicians (ACP) says physicians should not offer routine pelvic examinations to asymptomatic, average risk, non-pregnant women. ACP’s analysis of the evidence found that routine pelvic examination has no demonstrated benefit, rarely detects important disease, does not reduce mortality, and is associated with discomfort, false positive and negative examinations, and extra cost.
ACP’s guideline does not apply to Pap smear screening, only the pelvic examination. ACP states that when screening for cervical cancer, the recommended examination should be limited to visual inspection of the cervix and cervical swabs for cancer and for some women human papillomavirus (HPV), and does not need to include the bimanual examination. ACP found that the diagnostic accuracy of the pelvic examination for detecting gynecologic cancer or infections is low. ACP advises that the pelvic examination is appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.
ACP’s guideline includes High Value Care advice to help doctors and patients understand the benefits, harms, and costs of the pelvic examination so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices.
The guideline is based on a systematic review of 52 published studies that found little evidence to support routine pelvic exams for average-risk women with no gynecological symptoms. Among the findings, research showed that pelvic exams cause pain, discomfort, fear, anxiety, or embarrassment for about a third of women and some studies suggest that up to eight in 10 women experience emotional distress because of the test. In addition, false-positive results may lead to unnecessary, invasive, and potentially harmful diagnostic procedures.
The authors of an accompanying editorial predict that ACP’s guideline will be controversial because it recommends against an exam that has long been considered a fundamental component of the well-woman visit. They write, “Regardless of whether the ACP statement changes practice among obstetrician-gynecologists, it should provide a needed prompt for champions of this examination to clarify its goals and quantify its benefits and harms. Even if net benefit is ultimately demonstrated, the question of value will need to be addressed to understand the resources required to achieve that benefit.”
A. Qaseem, L. Humphrey, R. Harris, M. Starkey, and T. Denberg, for the Clinical Guidelines Committee of the American College of Physicians. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians.Annals of Internal Medicine (2014), 161 (1), 67-72. http://www.annals.org/article.aspx?doi=10.7326/M14-0701
H.E. Bloomfield, A. Olson, N. Greer, A. Cantor, R. MacDonald, I. Rutks, and T.J. Wilt. Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Women: An Evidence Report for a Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine (2014), 161 (1), 46-53. http://www.annals.org/article.aspx?doi=10.7326/M13-2881
G.F. Sawaya, and V. Jacoby. Screening Pelvic Examinations: Right, Wrong, or Rite?Annals of Internal Medicine (2014), 161 (1), 78-79. http://www.annals.org/article.aspx?doi=10.7326/M14-1205