Screening Pelvic Examinations Research Articles

Screening pelvic examinations are unnecessary in asymptomatic women 21 to 35 years old

Screening pelvic examinations are unnecessary in asymptomatic women 21 to 35 years old

No. 385-Indications for Pelvic Examination.

No. 385-Indications for Pelvic Examination.

ACOG Committee Opinion No. 754 Summary: The Utility of and Indications for Routine Pelvic Examination.

The pelvic examination has long been considered a fundamental component of the well-woman visit, and many women and gynecologic care providers view this visit as an opportunity to discuss sexual and reproductive health issues. Traditionally, a pelvic examination is performed for asymptomatic women as a screening tool for gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease; some obstetrician-gynecologists and patients consider it important in detecting subclinical disease, despite evidence to the contrary. Given changes in screening recommendations and the ability to screen for sexually transmitted infections using less-invasive methods, reevaluation of the role of the pelvic examination for asymptomatic, nonpregnant women is warranted. A limited number of studies have evaluated the benefits and harms of a screening pelvic examination for detection of ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes. Data from these studies are inadequate to support a recommendation for or against performing a routine screening pelvic examination among asymptomatic, nonpregnant women who are not at increased risk of any specific gynecologic condition. It is recommended by the American College of Obstetricians and Gynecologists that pelvic examinations be performed when indicated by medical history or symptoms. Women with current or a history of cervical dysplasia, gynecologic malignancy, or in utero diethylstilbestrol exposure should be screened and managed according to guidelines specific to those gynecologic conditions. Based on the current limited data on potential benefits and harms and expert opinion, the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider.

ACOG Committee Opinion No. 754: The Utility of and Indications for Routine Pelvic Examination.

The pelvic examination has long been considered a fundamental component of the well-woman visit, and many women and gynecologic care providers view this visit as an opportunity to discuss sexual and reproductive health issues. Traditionally, a pelvic examination is performed for asymptomatic women as a screening tool for gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease; some obstetrician-gynecologists and patients consider it important in detecting subclinical disease, despite evidence to the contrary. Given changes in screening recommendations and the ability to screen for sexually transmitted infections using less-invasive methods, reevaluation of the role of the pelvic examination for asymptomatic, nonpregnant women is warranted. A limited number of studies have evaluated the benefits and harms of a screening pelvic examination for detection of ovarian cancer, bacterial vaginosis, trichomoniasis, and genital herpes. Data from these studies are inadequate to support a recommendation for or against performing a routine screening pelvic examination among asymptomatic, nonpregnant women who are not at increased risk of any specific gynecologic condition. It is recommended by the American College of Obstetricians and Gynecologists that pelvic examinations be performed when indicated by medical history or symptoms. Women with current or a history of cervical dysplasia, gynecologic malignancy, or in utero diethylstilbestrol exposure should be screened and managed according to guidelines specific to those gynecologic conditions. Based on the current limited data on potential benefits and harms and expert opinion, the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider.

Screening Pelvic Examinations

Screening Pelvic Examinations

Is It Time to Abandon the Routine Pelvic Examination in Asymptomatic Nonpregnant Women?

In this issue of JAMA, the US Preventive Services Task Force (USPSTF) reports its recommendation statement on screening for gynecologic conditions with a pelvic examination in asymptomatic, nonpregnant women.1 Based on a rigorous assessment of available research studies, their respective methodological quality, and the associated harms and benefits,2 the task force determined that “current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. (I statement)

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

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. National survey from May 2010 to January 2011 asking obstetrician-gynecologists about the need for and importance of external inspection and speculum examination 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. Mail-in survey of a national sample of obstetrician-gynecologists. Probability sample of obstetrician-gynecologists from the American Medical Association Physician Masterfile (N = 521). Proportion of obstetrician-gynecologists who would perform external inspection and speculum examinations and consider these examinations to be very important. 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 important in the 70-year-old (63%) than in younger women (46-53%). Reasons rated as very important included identifying cancers and benign lesions, reassuring women of their health, and adhering to standard of care. Obstetrician-gynecologists would commonly perform external and speculum examinations in asymptomatic women and believe the external examination to be particularly important in older women for cancer detection. Clinicians should discuss limitations of screening pelvic examination guidelines and elicit health goals from older women to provide more person-centered gynecological care.

Update on Medical Practices That Should Be Questioned in 2015.

Overuse of medical care, consisting primarily of overdiagnosis and overtreatment, is a common clinical problem. To identify and highlight articles published in 2014 that are most likely to influence medical overuse, organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse, and to review these articles and interpret them for their importance to clinical medicine. A structured review of English-language articles in PubMed published in 2014 and a review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults. We reviewed 910 articles, of which 440 addressed medical overuse. Of these, 104 were deemed most relevant based on the presentation of original data, quality of methods, magnitude of clinical effect, and number of patients potentially affected. The 10 most influential articles were selected by author consensus using the same criteria. Findings included lack of benefit for screening pelvic examinations (positive predictive value <5%), carotid artery screening (no reduction in stroke), and thyroid ultrasonography (15-fold increase in thyroid cancer). The harms of cancer screening included unnecessary surgery and complications. Head computed tomography was an overused diagnostic test (clinically significant findings in 4% [7 of 172] of head computed tomographic scans). Overtreatment included acetaminophen for low back pain, perioperative aspirin use, medications to increase high-density lipoprotein cholesterol level, stenting for renal artery stenosis, and prolonged opioid use after surgery (use >90 days in 3% [1229 of 39,140] of patients). Many common medical practices should be reconsidered. It is anticipated that our review will promote reflection on these 10 articles and lead to questioning of other non-evidence-based practices.

Screening Pelvic Examinations in Adult Women

Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.

The Updated, Annual, Gynecologic Examination

<h2>Poster Presentation</h2><h3>Background</h3> The practice of annual gynecologic screening to identify problems at an early stage for intervention has traditionally been a component of women's health care. Patients and providers have accepted the schedule of these examinations, which includes cervical cancer screening and a pelvic examination. However, there is little evidence to support the benefits of such annual screening in low risk women. The Institute of Medicine (IOM), the Centers for Disease Control and Prevention, and the Office of Population Affairs (OPA) have developed recommendations for providing essential preventive services for women. Other professional organizations provide evidence‐based guidelines for cervical cancer screening. The American College of Physicians currently recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women. The American College of Obstetricians and Gynecologists (ACOG) further states that no evidence supports or refutes the annual pelvic examination and its performance should be based on shared decision making. <h3>Case</h3> Lucia, a 31‐year‐old healthy woman presented for her annual gynecologic examination. Her past history included negative annual Pap smears since age 18. As the office nurse or advance practice nurse using the most current evidence, what is the appropriate cervical cancer screening interval, and is a pelvic examination indicated? This poster presentation reviews current evidenced‐based recommendations for women's preventative health care, changes in cervical cancer screening protocols, and the evidence for the screening pelvic examination. The components of an evidence‐based, women's wellness visit is presented. <h3>Conclusion</h3> The wellness examination should be based on evidence‐based recommendations. In addition to breast and cervical cancer screening, this includes risk assessment for sexually transmitted infections, assessment of sexual wellness, screening for intimate partner violence, immunization review, and assessment of overall health and wellness. Preventive services should include pregnancy prevention with a focus on preconception care or options counseling if indicated. The prevention of chronic diseases through modifiable risks factors is stressed. The nursing profession has a long history of incorporating evidence‐based science into daily practice and of challenging long‐accepted patterns of providing care. A critical appraisal and redesign of the structure of the annual gynecologic examination can strengthen efforts to promote the overall health of women. Nurses can take leadership roles within the health care team to change protocols based on the best available evidence. After a careful review of Lucia's health history, she is eligible for Pap and human papilloma virus (HPV) cotesting every 5 years without a pelvic examination at today's visit.

Guidelines in Flux

INTRODUCTION: The American College of Obstetricians and Gynecologists (the College) recommends annual pelvic examination during routine well-woman care. Other organizations, notably the American College of Physicians, advise against screening pelvic examinations in asymptomatic women. We assessed primary care physicians' current practice patterns. METHODS: Internal and family medicine physicians (N=801) electronically were surveyed at all Mayo Clinic sites; 284 (36%) responded. Demographics were recorded. Comparisons between groups utilized Wilcoxon rank-sum tests for scaled survey items (eg, comfort or importance level) using SAS 9. P<.05 was significant. RESULTS: Nearly all (n=276, 97%) primary care physicians routinely perform pelvic examinations. Few (10%) referred patients to obstetrician–gynecologists (ob-gyns) solely for routine examinations, but internal medicine physicians were more likely to refer than family medicine physicians (P<.001). There was no difference in referral for male compared with female primary care physicians. The most common reasons for referral were patient preference for ob-gyns (n=81) and technically difficult examinations (n=66). Family medicine physicians reported more comfort with all components of the examination (P<.001). Internal medicine providers placed less importance on speculum placement (P=.002), identifying the cervix (P=.002), examining vaginal walls (P=.001), and bimanual palpation of the fundus (P=.02). More than half of respondents (n=154, 56%) thought examinations should be performed every 3 years for low-risk women. CONCLUSION: Despite evolving and conflicting guidelines, most primary care physicians currently perform pelvic examinations. Few refer patients to ob-gyns solely for this purpose. Family medicine providers appear more comfortable with examination technique than internal medicine physicians. Most primary care physicians felt pelvic examinations could be performed less frequently than recommended by current College guidelines.

Screening Pelvic Examinations in Asymptomatic, Average-Risk Adult Women

Pelvic examinations are commonly performed as part of the routine care visit in asymptomatic, nonpregnant, adult women to screen for cancer, infections, asymptomatic pelvic inflammatory disease, and other pathological conditions. Many clinicians and women believe that pelvic examination should be part of the annual well-women visits. However, routine pelvic examination is low-value care and has questionable benefit, and many clinicians believe that it should not be performed. This study presents available evidence on the diagnostic accuracy, benefits, and harms of routine screening for pathology during routine screening pelvic examinations in adult, asymptomatic, average-risk, nonpregnant women. These findings were the basis for the American College of Physicians (ACP) clinical practice guideline (Qaseem et al, Ann Intern Med 2014;161:67-72). Data were obtained by a systematic review of the published literature in the English language from 1946 through January 2014 using MEDLINE and hand searching. Assessed outcomes were evidence of benefits (decreased morbidity and mortality) and harms. No evidence was found that routine screening pelvic examination in asymptomatic, nonpregnant, adult women has any benefit, and there was indirect evidence that it does not reduce morbidity or mortality rates. Potential harms include overdiagnosis (false-positive findings), overtreatment (unnecessary laparoscopies or laparotomies), and diagnostic procedure-related harms. Patient-related harms (based on low-quality evidence) include fear, anxiety, embarrassment, pain or discomfort, and avoidance of necessary care. The annual cost of performing routine pelvic examination in the United States is substantial (?$2.6 billion). These findings show that routine screening pelvic examination is potentially harmful and does not reduce mortality or morbidity rates in asymptomatic adult women. Moreover, it adds unnecessary cost to the health care system in the United States. Based on these data, the ACP guideline recommended against use of screening pelvic examination in asymptomatic, nonpregnant, adult women.

Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians.

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the utility of screening pelvic examination for the detection of pathology in asymptomatic, nonpregnant, adult women. This guideline is based on a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. Evaluated outcomes include morbidity; mortality; and harms, including overdiagnosis, overtreatment, diagnostic procedure-related harms, fear, anxiety, embarrassment, pain, and discomfort. The target audience for this guideline includes all clinicians, and the target patient population includes asymptomatic, nonpregnant, adult women. This guideline grades the evidence and recommendations using the ACP's clinical practice guidelines grading system. ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women (strong recommendation, moderate-quality evidence).

Summaries for patients. Screening pelvic examination in nonpregnant adult women: recommendations from the American College of Physicians.

Summaries for patients. Screening pelvic examination in nonpregnant adult women: recommendations from the American College of Physicians.

Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for a clinical practice guideline from the American College of Physicians.

Pelvic examination is often included in well-woman visits even when cervical cancer screening is not required. To evaluate the diagnostic accuracy, benefits, and harms of pelvic examination in asymptomatic, nonpregnant, average-risk adult women. Cervical cancer screening was not included. MEDLINE and Cochrane databases through January 2014 and reference lists from identified studies. 52 English-language studies, 32 of which included primary data. Data were extracted on study and sample characteristics, interventions, and outcomes. Quality of the diagnostic accuracy studies was evaluated using a published instrument, and quality of the survey studies was evaluated with metrics assessing population representativeness, instrument development, and response rates. The positive predictive value of pelvic examination for detecting ovarian cancer was less than 4% in the 2 studies that reported this metric. No studies that investigated the morbidity or mortality benefits of screening pelvic examination for any condition were identified. The percentage of women reporting pelvic examination-related pain or discomfort ranged from 11% to 60% (median, 35%; 8 studies [n = 4576]). Corresponding figures for fear, embarrassment, or anxiety ranged from 10% to 80% (median, 34%; 7 studies [n = 10 702]). Only English-language publications were included; the evidence on diagnostic accuracy, morbidity, and mortality was scant; and the studies reporting harms were generally low quality. No data supporting the use of pelvic examination in asymptomatic, average-risk women were found. Low-quality data suggest that pelvic examinations may cause pain, discomfort, fear, anxiety, or embarrassment in about 30% of women. Department of Veterans Affairs.

Screening for Cervical Carcinoma in Developmentally Disabled Women in Residential Facilities

Our aim was to describe the results of Papanicolaou (Pap) smears obtained during routine pelvic examinations on virginal developmentally disabled women and to compare the incidence rate of abnormal cervical cytology to the general population. This study was descriptive and comparative. Subjects were a convenience sample of 230 developmentally disabled virginal women (mean age, 31 ± 9.6 years) who were living in a state-operated residential facility and had screening pelvic examinations and Pap smears. Cytological diagnoses were compared with a general population (n = 92, 151). Overall rate of abnormal Pap smears was significantly lower than the age-adjusted rate in the general population (z = 2.88, p <.01). All subsequent cytology in the study population reverted to normal. No evidence of cervical neoplasia was seen in the study population. Routine screening for cervical carcinoma is not indicated for this population of developmentally disabled women who have not had sexual inter-course.