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Is the Routine Pelvic Examination Obsolete?

Annual pelvic examinations have been routine care for women in the U.S. for decades and are widely tolerated as a necessary part of health maintenance. However, the latest guidelines from the American College of Obstetricians and Gynecologists (ACOG), recommend a decrease in the frequency of pap smear tests for most women, from annual to once every 2 to 3 years from ages 21-65, bringing into question: when a “pap” test is not needed, should the annual pelvic examination continue to be part of routine health exams for women?

In a Perspective published in the January 2011 Journal of Women’s Health, Carolyn Westhoff, MD, professor of Population and Family Health and Epidemiology at the Mailman School, reviews the value of the routine pelvic examination and its benefits and costs for healthy women who have no symptoms of disease.  Dr. Westhoff cites data that shows that for such women the pelvic exam is not needed to screen for sexually transmitted infections (STIs), is not needed to initiate hormonal contraception, and is not beneficial for early detection of ovarian cancer.

Dr. Westhoff also considers some potential harm of pelvic exams in healthy women. These include exposure to additional diagnostic evaluations that often lead to unnecessary surgery and consuming time during a wellness exam that could be put to better use. She further points out that pelvic examinations are notoriously uncomfortable and so disliked that it may prevent many women from seeking routine care in the first place.

“The clinical trial data show no evidence that pelvic examination improves the early detection of ovarian cancer or diagnosis of other conditions in women who have no symptoms,” says Dr. Westhoff, who is also a Columbia professor of Obstetrics & Gynecology. “Overuse of the pelvic examination contributes to high healthcare costs without any compensatory health benefit and eliminating them from most visits will free resources to provide services of proven benefit.” Overutilization of services is the most important contributor to the high cost of U.S. healthcare, the article notes.

In the U.S., the routine pelvic examination is the core of the periodic gynecological examination. Specific justifications for the pelvic examination include screening for chlamydia and gonorrhea infection, although as Dr. Westhoff points out, with today’s new technology, there are highly sensitive tests that can use urine or a vaginal self-swab rather than a speculum exam.

Frequent, routine pelvic examinations may partly explain why U.S. rates of ovarian cystectomy and hysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women. Observes Dr. Westhoff:

“Increasingly, we recognize that more services do not always lead to improved health outcomes and that often the opposite is true: that more services are associated with worse heath outcomes.”

Read interview with Dr. Westhoff in The Wall Street Journal.

February 17, 2011