In early July, 2014, the American College of Physicians (ACP) issued guidelines challenging the need for a vaginal speculum and bimanual (internal) pelvic exam as an integral part of a routine well-woman office visit. The ACP reviewed the evidence and concluded that the routine pelvic examination is not useful in screening for malignancies other than cervical cancer, and can lead to unnecessary evaluation and surgery, while also often causing discomfort and embarrassment and may actually be a deterrent to some women seeking gynecological care. Their recommendations are summarized as follows:
- Routine pelvic exam is not recommended in asymptomatic non-pregnant adult women
- This recommendation does not apply to the timing and need for cervical cancer screening
The cervical cancer screening tests… pap smears, liquid based paps and/or human papilloma virus (HPV) testing should include a vaginal speculum exam while visualizing the cervix and collection of samples, but does not need to include bimanual examination
- Screening for chlamydia and gonorrhea can be done with urine tests or vaginal swabs
As a Naturopathic Physician women’s health practitioner, I think these recommendations from the ACP are worrisome for women. Routine annual pelvic exams (yes still annually even when it is not the year to collect the pap smear), including visualizing the external genitalia, inserting the speculum and visualizing the cervix and vaginal walls, and a bimanual exam provide a wealth of important information even in women who do not have any symptoms. Many women have bacterial vaginosis or some other vaginal or cervical infection, severe vulvovaginal atrophy, cervical polyps, uterine fibroids, ovarian enlargement, vaginal wall growths, and/or vulvar skin disorders. Any of these can occur without symptoms and the only way we would know it is if the full exam was performed. The asymptomatic woman is indeed the woman who might benefit most from the routine annual pelvic exam. It has been hard enough to communicate to women the need for continued annual exams (which also include height, weight, blood pressure, temperature, pulse, breast exam, thyroid exam, heart/lung/abdominal exam and more) even when they don’t need a pap smear or HPV test that year. Too many women have ceased seeing their health care provider every year and only come every 3 years when the need a pap smear.
The ACP guidelines also differ from women’s health practitioners such as the American College of Obstetricians and Gynecologists. In 2012, they reaffirmed that the speculum and bimanual examination is a part of annual well-women visits in women 21 y.o. and older.
In addition, as a Naturopathic Physician, the annual visit is used to check in on nutrition, alcohol, nicotine, recreational and prescription drugs, stressors, exercise, sleep, dietary supplements, other health issues, changes in their health including weight gain or weight loss, and an eye towards prevention of diseases based on family history, aging, habits and select routine or specific testing.
With these ACP recommendations (which I will ignore), I am certain that we can predict that even less women will seek annual visits with their health care provider. I will encourage my patients to seek annual visits and be clear in communicating the value of each exam and each test if/when needed.
Bloomfield H, et al. Screening pelvic examinations in asymptomatic, average-risk adult women: An evidence report or a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014 Jul 1;161:46