Please stop doing unnecessary pelvic exams

EBM Focus - Volume 15, Issue 9

Reference: JAMA Intern Med. 2020 Jan 6.

Pelvic exams are uncomfortable, anxiety-provoking, and can lead to false-positive test results, unnecessary treatments, and overdiagnosis. Until relatively recently, pelvic examinations were included as part of annual check-ups for asymptomatic women. Starting In 2014, organizations including the American College of Physicians and the American Academy of Family Physicians began to recommend against screening pelvic exams in nonpregnant women, extending these recommendations to the Choosing Wisely Campaign. In 2017, the US Preventative Task Force (USPSTF) found insufficient evidence to assess the benefits and harms of screening pelvic exams in asymptomatic, nonpregnant women, and the American College of Obstetricians and Gynecologists (ACOG) published a 2018 recommendation that pelvic exams be conducted only in patients with relevant symptoms or medical history. Pelvic exams are no longer considered necessary to screen for sexually transmitted illnesses (STIs) or before beginning contraception (except for an intrauterine device [IUD]). Furthermore, routine screening for cervical cancer with a Pap test in women under the age of 21 is no longer recommended by the USPSTF, ACOG, or the American Cancer Society.

The National Survey of Family Growth (NSFG) included women and men aged 15-44 years and examined health care utilization in the United States from September 2011 to September 2017. A recent study using these survey data included 3,410 female respondents aged 15-20 years who answered questions about whether they’d received a bimanual pelvic examination (BPE) or Pap test. Medical indications for a BPE included pregnancy, IUD use, treatment for an STI in the past 12 months, or other medical concern. If a respondent received a BPE without one of these indications, it was considered potentially medically unnecessary. Pap tests were considered medically unnecessary for all respondents because cervical cancer screening is not recommended in women under age 21 years, except in women with HIV who are sexually active. Information about HIV status was not collected as part of the NSFG.

About a quarter (23%) of the 3,410 women included in this study received a BPE in the prior 12 months, and 54% of these examinations were determined to be potentially unnecessary. Nineteen percent of women had received a Pap test in the past year (all potentially medically unnecessary). The vast majority (97.7%) of unnecessary BPEs were performed during the same visit as an unnecessary Pap test.

These findings indicate that many adolescent women in the United States receive an unnecessary pelvic exam despite guidelines recommending against this. However, because the NSFG data collection began before the publication of some of the guidelines that now recommend against unnecessary BPEs in this population, it is difficult to determine from this study whether rates of unnecessary exams have decreased since their publication. Unnecessary exams appear to be more commonly provided for women who are receiving STI screening or using contraception, despite neither hormonal contraception nor STI screening being considered sufficient justification. Clinicians who perform unnecessary BPEs also appear to be more likely to perform unnecessary Pap tests. This study highlights the need for a major educational outreach program to speed the adoption of the current evidence-based guidelines.

For more information, see the topic Cervical Cancer Screening in DynaMed.

DynaMed EBM Focus Editorial Team

This EBM Focus was written by Terri Levine, PhD, Senior Medical Writer in Obstetrics and Gynecology at DynaMed. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.