ACP recommends against screening pelvic exam, finds harms outweigh benefit

A new ACP guideline recommends against performing screening pelvic examinations in asymptomatic, nonpregnant adult women.

The guideline is based on a new evidence report, and both were published in the July 1 Annals of Internal Medicine. The report was a systematic review of all related evidence published in English between 1946 and January 2014, a total of 52 studies.

The studies provided no data to support the routine use of screening pelvic examination (excluding cervical cytologic examination) for reducing morbidity or mortality from any condition, the review concluded. Use of the exam to screen for ovarian cancer has shown a positive predictive value of less than 4%, the researchers found, noting that the practice was discontinued for lack of benefit in 1 large ovarian-cancer screening study, and it has not been found to increase detection of any other cancers. No studies have assessed the effect of pelvic examination on pelvic inflammatory disease, bacterial vaginosis, or other noncancerous conditions, they noted.

The exam has been associated with harms including pain, discomfort, fear, anxiety, or embarrassment, which suggests that about 30% of women may suffer these consequences, the review found. Other arguments against the procedure include unnecessary follow-up care for false-positives, including laparoscopies or laparotomies, and unnecessary health care spending, the guideline noted. The comparison of these benefits and harms led the College to recommend against routine use of screening exams in asymptomatic, nonpregnant, adult women in a strong recommendation based on moderate-quality evidence.

The guideline does not apply to Pap smear screening. A cervical cancer screening should be limited to visual inspection of the cervix and cervical swabs and does not need to include the bimanual examination, the guideline said. The guideline authors noted that data have shown continued overuse of cervical cancer screening in comparison to current recommendations, and they called for research into strategies to reduce overuse of pelvic examinations.

The authors of an accompanying editorial predicted that the guideline will be controversial and expressed uncertainty about whether it will change practice among obstetrician-gynecologists. However, it should spur more analysis and debate on the issue, the editorialists said.

“With the current state of evidence, clinicians who continue to offer the examination should at least be cognizant of the uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow,” they concluded.