Insufficient Evidence for Screening for Gynecologic Conditions With Pelvic Examination
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Many conditions that can affect women's health are often evaluated through pelvic examination. Although the pelvic examination is a common part of the physical examination, it is unclear whether performing screening pelvic examinations in asymptomatic women has a significant effect on disease morbidity and mortality.
Objective
To issue a new US Preventive Services Task Force (USPSTF) recommendation on screening for gynecologic conditions with pelvic examination for conditions other than cervical cancer, gonorrhea, and chlamydia, for which the USPSTF has already made specific recommendations.
Evidence Review
The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women 18 years and older who are not at increased risk for any specific gynecologic condition.
Findings
Overall, the USPSTF found inadequate evidence on screening pelvic examinations for the early detection and treatment of a range of gynecologic conditions in asymptomatic, nonpregnant adult women.
Conclusions and Recommendation
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. (I statement) This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou smear, screening for gonorrhea and chlamydia).
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Additional Info
Disclosure statements are available on the authors' profiles:
Screening for Gynecologic Conditions With Pelvic Examination: US Preventive Services Task Force Recommendation Statement
JAMA 2017 Mar 07;317(9)947-953, K Bibbins-Domingo, DC Grossman, SJ Curry, MJ Barry, KW Davidson, CA Doubeni, JW Epling, FA García, AR Kemper, AH Krist, AE Kurth, CS Landefeld, CM Mangione, WR Phillips, MG Phipps, M Silverstein, M Simon, AL Siu, CW TsengFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
With over 44 million pelvic examinations done annually in the US, the controversy continues regarding the role of the pelvic examination for screening in asymptomatic, non-pregnant women. In 2014, the American College of Physicians (ACP) recommended against performing the screening pelvic examination in such women. The American Academy of Family Physicians adopted the same recommendation. Now, the United States Preventive Services Task Force (USPSTF) has published a formal statement based on a systematic review of the evidence. They conclude that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, non-pregnant adult women (I statement). This excludes during screening for cervical cancer with a Pap smear or screening for gonorrhea and chlamydia.
The USPSTF evaluated the benefits and the harms of performing annual screening pelvic examinations. It found inadequate evidence of benefits of screening for several gynecologic conditions and found no studies showing benefit on mortality, morbidity, or quality of life. There was also inadequate evidence on the harms of screening. Some studies showed potential for false positives and false negatives for conditions such as ovarian cancer. Potential harm also includes patients undergoing unnecessary tests and treatments; however, the evidence was limited.
With the changes in cervical cancer screen intervals (3–5 years), performing the pelvic examination in the “annual” physical or well-woman examination has come under question. Historically, the pelvic examination includes examination of the external genitalia, internal speculum examination, bimanual palpation to examine the uterus, ovaries, and adnexa, and occasionally a rectovaginal examination. Clinicians have relied on the annual pelvic examination as a screening tool to detect uterine and ovarian abnormalities or infections, such as bacterial vaginosis, trichomoniasis, and pelvic inflammatory disease.
As I have commented before, due to limiting factors such as a patient’s body habitus, feeling an ovarian mass or other significant uterine pathology can be very difficult. As clinicians, we each likely have our own anecdotal experiences of finding that rare mass or abnormality in our patient that indeed turned out to be malignant or significant; however, if we explored the evidence and the number needed to treat to have diagnosed that 1 patient, we realize our positive predictive value is significantly low and this is not cost-effective. Yet, we want to ensure we are meeting the healthcare needs of our patients.
In line with the American Congress of Obstetricians and Gynecologists (ACOG) recommendations, the decision to do an annual pelvic examination or not to do one should be a decision discussed with the patient using a shared decision model in which the physician reviews the risk profile of the patient, shares the pros and cons of the evidence, and a mutual decision is then based on the patient’s desires, needs, and preferences.