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Questioning the Annual Pelvic Exam

A new article in the Journal of Women’s Health by Westhoff, Jones, and Guiahi asks “Do New Guidelines and Technology Make the Routine Pelvic Examination Obsolete?”

The pelvic exam consists of two main components: the insertion of a speculum to visualize the cervix and the bimanual exam where the practitioner inserts two fingers into the vagina and puts the other hand on the abdomen to palpate the uterus and ovaries. The rationales for a pelvic exam in asymptomatic women boil down to these:

  • Screening for Chlamydia and gonorrhea
  • Evaluation before prescribing hormonal contraceptives
  • Screening for cervical cancer
  • Early detection of ovarian cancer

None of these are supported by the evidence. Eliminating bimanual exams and limiting speculum exams in asymptomatic patients would reduce costs without reducing health benefits, allowing for better use of resources for services of proven benefit. Pelvic exams are necessary only for symptomatic patients and for follow-up of known abnormalities.

Screening for Chlamydia and Gonorrhea

Screening for Chlamydia in young women is evidence-based: it reduces the rate of pelvic inflammatory disease. New tests are available (on urine and self-administered vaginal swabs) that do not require a pelvic exam by a doctor. They are sensitive and cost-effective. Supporting references are listed in the article.

Hormonal Contraception

Doctors used to require pelvic exams before they would dispense prescriptions for oral contraceptives. This was never shown to be necessary; no findings from these exams influenced the decision to issue a prescription. One concern, the possibility of a pre-existing pregnancy, can’t be entirely ruled out by a pelvic exam; but the risk can be minimized by starting the pills after a normal menstrual period. Now all the major guidelines (from the FDA, WHO, ACOG, Planned Parenthood, etc.), specify that a pelvic exam is not required for hormonal contraception.

Cervical Cancer Screening

Pap smears have been proven effective in reducing morbidity and mortality from cervical cancer. Speculum exams are necessary to obtain specimens for Pap smears, but Pap smears need not be done annually and speculum exams need not be accompanied by bimanual exams. Current recommendations are to begin screening at age 21 and to re-screen at intervals of 2-3 years. New technology currently in development may eventually allow for equivalent screening without a pelvic exam.

Ovarian Cancer

The evidence shows that bimanual exams are useless for detecting ovarian cancer, and they are no longer recommended for this purpose.

Other Benefits/Risks of Pelvic Exams

While other conditions such as fibroids, ovarian cysts, and yeast infections can be detected by examining asymptomatic women, there is no evidence that early diagnosis improves outcomes. Over-screening for cervical cancer has been shown to lead to harm. Findings on pelvic exams can be false positives and can lead to unnecessary interventions.

“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.”

Is It Time to Abandon the Annual Pelvic Exam?

Yes, I think so. The existing evidence indicates that omitting it in asymptomatic women would not affect health outcomes. This article is representative of a growing consensus in the medical community, especially in other countries; but many US doctors are still doing annual pelvic exams. I suspect (just my opinion) that they are afraid of looking stupid or getting sued if they miss something, or are clinging to what they were taught to do out of inertia.  Meanwhile, science-based doctors are leaning away from annual physical exams in general. As this website says,

The annual physical exam is beloved by many people and their doctors. But studies show that the actual exam isn’t very helpful in discovering problems. Leading doctors and medical groups have called the annual physical exam “not necessary” in generally healthy people.

Even in patients being followed for diagnosed diseases, the physical exam sometimes degenerates into a token ritual. I’ve noticed that although I have no heart or lung symptoms, my own doctors like to check my lungs at every visit by putting the stethoscope on four spots (right, left, front and back) for one breath each, and to check my heart by applying the stethoscope briefly to one spot. I tolerate it because I know it makes them feel better, but I consider it totally useless.
Admittedly, there is a human element involved: hands-on interactions and the perception of “doing something” can be reassuring and can enhance the doctor/patient relationship. But can’t a caring clinician attain those same benefits within the realm of science-based medicine? A doctor’s time is better spent on proven health screening measures and in educating and counseling patients than in carrying out nonproductive rituals.

Posted in: Obstetrics & gynecology

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56 thoughts on “Questioning the Annual Pelvic Exam

  1. cellculturequeen says:

    “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.”

    The latter part doesn’t appear to be true for Germany. I don’t have any statistics, but for most women here the pelvic is still a yearly ritual, and there’s a persisting belief that hormonal contraceptives can only be prescribed by a gynecologist. It took me years to realize I could get the prescription from my GP with much less hassle, as the gyno would usually hold it hostage unless I came in for an exam. The youth magazines I read in the 1990s even claimed that women on the pill had to be examined TWICE a year.

  2. “Hands-on interactions and the perception of “doing something” can be reassuring and can enhance the doctor/patient relationship. But can’t a caring clinician attain those same benefits within the realm of science-based medicine?”

    What hands-on interactions do you recommend for routine visits? Blood pressure?

  3. Jan Willem Nienhuys says:

    In the Netherlands there used to be a custom of annually checking users of hormonal contraceptives. But the Dutch Association of General Practitioners (NHG) decided in 1989 that such checking should be very limited, and they published this in their official standards.

    For a first consult the checks should consist of:
    1. anamnesis for contra-indications
    2. explanation of side-effects
    3. blood pressure measurement (pressure > 100 mmHg after three months is a contra-indication for continuation of oral contraceptives; if bloodpressure stays normal, there is no more need for additional check-ups)
    4. explanation about the use

    Internal examination only when there are specific complaints.
    This change in standards came of course after many GP’s already had come to the conclusion that regular internal examinations were useless.

    Well before 2000 the NHG decided that any kind of checks were unnecessary. One of the reasons was that frequent checks medicalise; it caused many women to think that any complaint is due to The Pill.

    So reading the above post gave me the feeling of a message from ‘the land that time forgot’.

  4. cellculturequeen says:

    So reading the above post gave me the feeling of a message from ‘the land that time forgot’.

    I seem to be living in that land.
    This is highly unscientific of course, but I just checked a German female health message board I used to read when I was younger, mostly frequented by young women in their teens and early twenties. In a thread about the frequency of gynecological exams, every single commenter said they went at least once a year, about two thirds twice a year. They seem to believe this is normal and neccessary on hormonal birth control. This is kind of depressing, but apparently the norm in this country.

  5. Not sure if PC users are seeing this, but there’s a font size issue at the end of the article, at least on my Mac.

    Nice, relevant article, although I would saying calling the annual pelvic exam “beloved” (quoted, not HH) by patients is not the descriptor I’d use.

  6. Jan Willem Nienhuys says:

    @ cellculturequeen

    Your remarks illustrate that ‘medical culture’ is a strictly local affair. I don’t know about other parts of the world, but passing a border in Western Europe doesn’t involve having to show your passport anymore and changing money is also passé, but traditions and fads are completely different.

    Not much related to this: some years ago there was an epidemy of symphysiolysis in the Netherlands. (I remember vividly a case of a patient who was seriously invalidated by it, and who got instantly cured by an iterant preacher in her hometown Eindhoven.) But it stopped at the border. I believe this epidemy also happened in Norway.

  7. Jan Willem Nienhuyson

    “Your remarks illustrate that ‘medical culture’ is a strictly local affair.”

    This is curious. Why do you suppose that is? Is it education of doctors, public health departments, differing health payment systems? I wonder, do we have a similar phenomenon between the U.S. states or regions? I have heard from parents who live in different regions who seems to have doctors who take a quite different approach, I never could tell if it just individual differences or state/regional.

  8. jpmd says:

    Good points. As a family practice doc, I admit to the stethoscope routine, and agree it is limited value. However, if you look at the risk/benefit ratio, the risk is zero, the cost is just a few seconds, so any minimal benefit makes the return huge. I have picked up arrhythmias, murmurs, and even skin cancers when the patient bares their back to be listened to. However, the most important part of it may well be the interaction and touch, which impacts the doctor-patient interaction. Unfortunately, the woo masters do that well, and perhaps the exam helps defections to the dark side.

  9. Steve Packard says:

    Regarding Screening for Chlamydia and Gonorrhea, is this necessarily something that really has to be applied to all women? There are some people in our society who, shocking though it may seem, are not sexually active and don’t have sex for a period of more than a year. Then there are others who are in a monogamous relationship and unless their partner is unfaithful, one would not expect a sexually transmitted infection to be introduced to them.

    Could such individuals be ruled “low risk” and therefore not necessarily requiring of such regular screening?

  10. “Then there are others who are in a monogamous relationship and unless their partner is unfaithful, one would not expect a sexually transmitted infection to be introduced to them.”

    Unfortunately, one often doesn’t expect that your beloved is screwing anyone available, including your best friend…”

    Whoops, did I say that? I’ll be nicer. Many people believe they are in a monogamous relationship when they are not.

  11. megancatgirl says:

    “Regarding Screening for Chlamydia and Gonorrhea, is this necessarily something that really has to be applied to all women? There are some people in our society who, shocking though it may seem, are not sexually active and don’t have sex for a period of more than a year.”

    I think it’s still worth checking because plenty of women are the victims of rape or sexual assault and it might not be something that they will tell their doctor. There’s still too much shame associated with it still in our culture.

    On top of that, there are plenty of sexually active people that will lie and say they are not sexually active, again because of stigma and shame. And there’s really no good way for a doctor to tell those people apart from the ones who are truly celibate. This is probably most common among teenagers so maybe older adults can be taken at their word.

    There are also people who are at risk but don’t know it. Thanks to sexual taboos and abstinence-only education, there are plenty of technical virgins that are still sexually active but don’t realize they are at risk.

    Also what micheleinmichigan said. It’s really not as simple and straightforward as it seems, especially when it comes to sex.

  12. desta says:

    Perfect timing, as I get ready to go in for an ob/gyn exam that I’ve avoided for the last two years. No more guilt, even if they try to make me feel bad about it. Too bad the insurance dollars are being wasted, but stuff like scientology screenings are covered under our very common insurance plan (yes! for real), so I guess it could be worse.

    It’s true that if I want a prescription for anything, I have to be examined 1x/yr.

    @micheleinmichigan: Totally. ;)

  13. LovleAnjel says:

    I would be so happy to drop the pelvic exam, and the tedious waiting for my cervical results to arrive in the mail (and the horrible “not normal but not abnormal” results).

    For many women, this is their annual physical and meeting with their doctor. Drop it and lots of people will not go to see their doctors.

  14. Amy says:

    as others had said above, maybe it should be annual for a certain age group or lifestyle. Through college, I definitely would prefer (and did) to have my annual exam, which was beneficial. Now, older, married, with child, it would be preferable to me to go every other year. For those who say one may not know they’re in a monogamous relationship, true, but that’s why it could change to every other year, rather than yearly, or if you’re exhibiting symptoms.

  15. spacebabe47 says:

    Ugh, I really hate that birth control prescriptions are tied to an annual pelvic exam. It’s like the prize you can only win if you agree to have someone scrape at your cervix.

    I live in Canada and I flew home to the States for my sister’s wedding. On my way to the airport, I remembered that I forgot to pick up my new Nuvaring, that I would need while I was away. Not wanting to mess up my cycle and need backup barrier methods for a month, I went on a quest to get a ring one I got to my hometown.

    Luckily, after a few days I was able to get into the low-income womens’ health center. I am a grad student an do live below the poverty line, so I qualified. I doubt any gyno would have been able to see me on such short notice. They refused to just give me a ring, even though I had a the oldone on me, I had to have a pelvic exam first. I had no choice to agree, even though I had one about 6 months earlier. So I spread my legs, let the doctor fell around down there and scrape some cells of my cervix. We wasted everyone’s time, but I got what I came for (and at no charge).

    I guess they were under no obligation to believe me, but I don’t thing I would have had to go through an invasive exam to get a small, emergency supply of any other perception drug.

  16. Rick says:

    @StevePackard

    It is part of the NCQA-HEDIS measures for health plans. Many insures track primary care providers on this and some give bonuses for doing the screening. However, the measure is for sexually acitve women between 16 and 28 I believe. The standard are several ways to determine “sexually activeness”. The most common is birth controll use. While it is not a perfect measure (I have yet to see one) I believe the thought behind it is vailid. Even though at my prior empolyer we would have a nun appear in the demonator because she was on a birth control medication (for heavy period I believe).

  17. Dpeabody says:

    I can’t help but think that in 50 years people will look back on these screenings and say “You had to do what!?” Hopefully new technology will allow a more convenient/comfortable screening process.

  18. tanha says:

    Harriet,
    One could argue that doing exam can also help with “upcoding” the visit, right? It strengthens justification for coding greater than a 99213 on E&M visit and having yearly physicals generates revenue for the physician as well. Not that that’s a good thing, just mentioning what other motivations are perpetuating exams that are not backed by science.

  19. Harriet Hall says:

    @Alison Cummins
    “What hands-on interactions do you recommend for routine visits? Blood pressure?”

    It is more cost-effective for BP to be taken by others with lower salaries. The MD’s time is better used in activities requiring more education. It would be presumptuous of me to recommend any hands-on interactions that have not been studied and are not evidence-based; but things like shaking hands and touching/examining areas of concern to the patient would seem to be appropriate. Human interactions will vary with culture and custom and with individual styles.

    @jpmd
    “any minimal benefit makes the return huge”

    That is the argument made for all kinds of other screening procedures in asymptomatic people, but it is not valid unless it can be shown that the benefit exceeds the risk. A careful study might show that the “huge return” is outweighed by false positives, unnecessary follow-up procedures, costs, and worries. It might show that the earlier detection of skin cancers, arrhythmias, etc. did not lead to measurable improvements in morbidity and mortality.

    @Steve Packard,

    Chlamydia/gonorrhea screening is not recommended for all women, only for young women where screening has been proven useful.
    You can’t depend on a patient’s self-reporting of sexual activity. People lie.

    @LovleAnjel,
    “For many women, this is their annual physical and meeting with their doctor. Drop it and lots of people will not go to see their doctors.”

    I don’t see that as a valid reason to inflict an annual pelvic exam on all women. An annual doctor visit may not be productive. It could be replaced by a health maintenance visit for evidence-based screening and education about prevention, and those functions might be better carried out by auxiliary personnel at lower expense.

    @Amy,
    “maybe it should be annual for a certain age group or lifestyle”

    Maybe, but without evidence, how would you decide which groups to examine annually?

  20. Enkidu says:

    spacebabe47 said: “Ugh, I really hate that birth control prescriptions are tied to an annual pelvic exam. It’s like the prize you can only win if you agree to have someone scrape at your cervix.”

    So true. Although, after all the poking around in there I had for my fertility treatments, the annual exam doesn’t bother me that much anymore. Still, if it’s not needed, I’d love to skip it!

  21. JMB says:

    Thank you for a nice article, Dr Hall.

    I think there has been a shift in the population demographics of birth control users since it was originally introduced. I think BCPs were more commonly used by younger women, and IUDs were more common in older women, until IUDs were withdrawn from the American market because of malpractice liability. Furthermore, BCPs replaced condoms as a birth control method, and so were initially associated with higher rates of STDs. I don’t think the original guidelines were ever updated to reflect the changing population demographics of BCP users. Even though there had originally been scientific evidence to support the recommendations for screening pelvic exams, the original risk benefit calculations were based on a select population of users, and the patterns of use changed. When the characteristics of the population of users change, so do the risk benefit calculations. The composition of BCPs also changed.

    It is not always that past scientific thinking was originally wrong. Sometimes science based medicine changes answers because of changes in patterns of use, diseases, or treatments. Skepticism means that science must periodically review it’s own answers.

    It is part of the NCQA-HEDIS measures for health plans. Many insures track primary care providers on this and some give bonuses for doing the screening.

    That’s a good point. Sometimes insurance companies get overbearing to patients/doctors when they chase high scores on statistics recorded for NCQA-HEDIS. We used to get patients that complained that they didn’t want a screening mammogram but their doctor insisted on it. In checking on why it was happening, we were told it was because the insurance company wanted to brag about high scores on quality measures, I presume the insurance companies were using the NCQA measures in marketing to business group health purchasers. When the government reports those measures as “quality measures” or “healthcare outcomes” or “healthcare report cards” then providers who are willing to let patients make their own decisions about risks don’t end up at the top.

    I haven’t seen those NCQA-HEDIS guidelines lately. That might be a potential topic for science based medicine.

  22. Jan Willem Nienhuys says:

    @ micheleinmichigan on 01 Mar 2011 at 8:26 am

    I have no clear idea why such medical customs are so local. In the case of advice for contraception, the Dutch health system is one where a patient goes to the GP first, who then may refer to a specialist if necessary. The situation in other countries is quite different. Going to an ob/gyn specialist for something as simple as a prescription for a contraceptive would sound rather strange over here. With about 1 ob/gyn specialist per 15,000 people they are already busy enough with difficult deliveries, gynaecological cancers, IVF-procedures, endometriosis. Ordinary low risk deliveries are done by midwives and in 36% of the cases at home, if I recall correctly

    The unity of medical culture within a country is easy to explain: the curriculums of the universities are standardised, there are professional organisations and just one disciplinary court and the physicians form a tight cooperating network.

    This leads to contrasts where in one country doctors and patients both are averse to medication unless it is really necessary, whereas in another country a physician won’t be taken seriously if s/he doesn’t prescribe several medicines after each consultation.

    The example of symphysiolysis is different. That epidemy was caused by patient groups advertising their complaints. That gossip circuit strictly stays inside national borders. Usually people don’t read magazines or meet people from other countries. One’s relatives usually live in the same country. National celebrities usually are totally unknown if you cross the border (where people often speak a different language too). In Belgium the Dutch speaking people and the French speaking people hardly know each other. Ask any national of country X whether s/he knows anything about the politics of country Y and you will get a blank stare. If you are lucky people may know the name of a prime minister in a large neighbor country.

    These separations of cultures can be found in many different aspects of life, not only medicine. Just recently I was reminded of the practice of graphology. This is a kind of pseudoscience that is taken very seriously in France and Germany. A single dissertation in 1963 in the Netherlands was decisive in making graphology over here something that in the course of the years degenerated into something considered akin to astrology. In France belief in psychoanalysis is still rampant. On the other hand, talking to trees, believing in gnomes and special chakras for leaders is quite normal in Dutch upper classes and one government department (of housing and land use and environment) has a special Fengshui meditation room that has been cleansed of earth rays by an earth ray specialist, and it least one university is deep into investigation homeopathy for farm animals.

  23. LovleAnjel says:

    Thanks for clearing that up, Dr. Hall. I guess my concern was “How would we replace/encourage the annual visit?”…a visit instead for general health screening would be great.

    This is about people with cervixes (cervices?), but since my husband isn’t required to go to a dr for anything, he doesn’t go to a doctor for ANYTHING. He has never met the PCP insurance assigned him, and if he needs anything other than emergency care he’ll probably have to wait months to see them for the “intro” visit (based on how practices work around here). Since I have to see my PCP once a year, we have an established relationship and I am comfortable seeing her for other issues and bringing up “sensitive” topics.

    With compulsory annual visits of some sort, you establish a dr-patient relationship that is more likely to deal with issues before they get too bad.

  24. CarolM says:

    Where did the annual exam tradition come from, anyway? was it something sole breadwinners did for their life insurance policies? My internists never pushed it, and my current one always acts a little bemused when I show up faithfully every year. Everyone over 50 should have an annual exam, right? or so I thought.

    Around here (NW USA) no MD ever suggested I needed to come in every year, esp after the Pap became a biannual test. Gotta give them credit, because I can tell business is slow right now (I can get in the same day I call). I do like making sure my doctor is still around, though. Female in internists are at a premium.

  25. Jan Willem Nienhuys – Thanks for the thoughtful answer. Alot of things I never considered.

    umm, earth rays are bad, I guess? :)

  26. “Where did the annual exam tradition come from, anyway? was it something sole breadwinners did for their life insurance policies? My internists never pushed it, and my current one always acts a little bemused when I show up faithfully every year. Everyone over 50 should have an annual exam, right? or so I thought.”

    I thought the annual exam idea was for a pap smear. The they do the chest, ear, throat, whatever, cause they got you in there.

    Personally, I think it’s good to have some relationship with a doctor before everything starts falling apart, physically. For me, the falling apart started when I was thirty and it was sorta a drag trying to convince a doctor I didn’t know that “really” I have these symptoms and they are new, I’m not normally always complaining about some pain or other.

    I’m not sure how “having a relationship with a doctor” can be accomplished without some waste, though.

  27. Kultakutri says:

    So I was right in my intuitive opinion that unless I have a problem, I have no reason to see a gyno.

    Regarding sexually inactive folks… well, I’ll throw in a bit of TMI. Because, well, technically, I lost my virginity at my first and I swear by all gods that are willing to listen, last gyno visit. I had issues, that’s it. I was in rather advaced age of 26-ish, was asked whether I had had intercourse, I asked why the hell the doc wants to know, he answered Because it’s a part of anamnesis. Or some such. I hear that the specula come even in smaller sizes for this purpose. Apparently, the doc either didn’t know about it (I did, only from reading the internetz, by the way), or he just wouldn’t believe me, as I guess. Because, hell, if the average of first intercourse is 17, everyone has to do it at least by 17 and half. Well… ick.

    Regarding the stethoscope: I’d welcome some linkies – not that I wouldn’t be able to google something but I’m much less of an expert than the informed public. I’d throw that research on my GP, that’s it. I hate people touching me and she knows, she has all my mental problems written down in my file.

  28. papertrail says:

    It’s disconcerting to me to hear that I’ve been (and all of society has been) wasting time and money on procedures that aren’t doing any (or much) good. Even the stethoscope exam is a waste of time?! I certainly don’t approve of doctors using procedures just to establish some kind of rapport (not at >$400 for a new patient exam, and hundreds for subsequent visits).

    I asked my doctor to not practicing defensive medicine on me (I can’t afford the almost knee-jerk reaction to order expensive tests, prescription, and out-referrals every time I mention any concern), and have mentioned the latest recommendations to do mammograms and paps/pelvic exams every other year instead of yearly. She is adamant that the new recommendations are wrong. She would view me as a difficult patient if I didn’t follow her beliefs on this. It is engrained in her that early detection is always a life saver.

    I use ESTRING, and maybe that’s reason enough for me to allow yearly paps and pelvic exams, but I really don’t know now. I do know that she wouldn’t renew my prescription otherwise.

    I feel confused now about what I should do. I hate those internal exams, especially now knowing they may not be necessary.

    Re: lower hysterecotmy rates in other countries, are their related outcomes the same as in the US (the statement implies so, but just want to make sure).

  29. Harriet Hall says:

    @papertrail:

    I found this reference about ovarian cyst surgery:
    “Ovarian cysts are a common cause of hospital admission in both countries. The higher rates in the United States are not associated with earlier diagnosis of ovarian cancer.”

    http://www.ncbi.nlm.nih.gov/pubmed?term=westhoff%20clark%20benign%20ovarian%20cysts

    I couldn’t find the reference for hysterectomy rates, but
    see http://www.ncbi.nlm.nih.gov/pubmed/7746172

    @Kultakutri,

    Remember I was only talking about the stethoscope being useless for screening purposes in asymptomatic people. As far as I know, no research has substantiated any significant benefit from such screening; therefore no linkies. :-(

  30. Jan Willem Nienhuys says:

    earth rays are bad, I guess?

    Earth rays were thought up around 1932 by a German baron Gustav von Pohl, who published a book about it. He thought these Erdstrahlen were what made dowsing rods move. He was unsure of their origin (cosmic rays reflected against undergrond water veins or coal layers or simply radiated from or concentrated by a lens like action by those water veins). They form strip like zones of about 1 dm wide, and having your bed or your favourite chair on such a strip is bad for your health. Von Pohl was able to explain many cases of cancer by his theory. He also sold little boxes that supposedly kept the rays away. Von Pohl was unmasked as a charlatan in 1935, and died in 1938. Ever since then the belief in Erdstrahlen has been quite strong in Germany. It became fashionable in the Netherlands after 1945 by the activity of pupils of Von Pohl. Finally the Dutch Academy of Sciences decided to investigate and they wrote two thick reports, which did a lot to quench this superstition for a long time – in the Netherlands. By the principle of locality these reports had no effect outside of the Netherlands. The German government commissioned an expensive investigation around 1988 to two ‘believers’, with rather predictable results; just imagine the US federal government asking Deepak Chopra and Lynne McTaggart to investigate quantum medicine.

    It all goes to show: 1. if you want to combat superstition and quackery you have to do it locally. 2. It helps enormously if a prestigious scientific institution puts some effort in serious investigation and comes forward with a clear statement.

    (Unfortunately there is also 2′: if a prestigious institution keeps investigating without ever coming to conclusions, then quackery festers on, helped by the prestige of having serious scientists look into it.)

  31. Amy says:

    Dr. Hall:
    @Amy,
    “maybe it should be annual for a certain age group or lifestyle”
    Maybe, but without evidence, how would you decide which groups to examine annually?

    True, I was thinking that based on personal experience. But, I would think screening women during an age group that has most sexual partners per given time would be a place to start. I would think there are already surveys out there showing this, I thought I’ve heard the college years as this. If this were true, you may make it yearly for 16-25yr olds. Then, you could survey when else. My female friends have increased their sexual partners after divorce, which would be a good time to see your GYN.

    To sum up, I was thinking, based on personal and friends’ experiences, guidelines for 16-25, and any women sexually active with multiple partners (assuming those over 25 would be mature enough to come in), or symptoms, otherwise, come every other year. Reading that now, it sounds judgmental, and favors women in presumably monogamous or non-sexual relationships to come less often, which was not what I intended (although, personally, I would prefer every other year).

    Funny you wrote this, last yr I asked my GYN about the changes in pap smear recommendations and if that meant I didn’t have to come every year, and he said, ah, but there’s still the pelvic exam. Hopefully, that will change too.

  32. “Funny you wrote this, last yr I asked my GYN about the changes in pap smear recommendations and if that meant I didn’t have to come every year, and he said, ah, but there’s still the pelvic exam. Hopefully, that will change too.”

    My doctor (I see a GP not GYN) told me last year that due to my age, I no longer needed the annual pelvic. Can’t remember how often she recommended. I generally mean to do an annual appointment regardless*, but I’m perfectly happy to avoid the “beloved” :) pelvic.

    I have to admit, though, that my one concern about skipping the pelvic is that my mother died from uterine cancer. Honestly, I’d rather not go into a whole uterine cancer research mode. But, I have no idea if that’s found in a pelvic exam, through symptoms or what symptoms, etc.

    I should probably talk with my GP about it, but often our appointments are so full of consults on thyroid, meds, asthma, meds, other related complaints that there’s not much time for the general education, family history stuff.

  33. Brett says:

    As a family doctor in Australia, I couldn’t agree more with this post.

    The prevailing culture here down under seems closer to the evidence than what you describe in the US: 2-yearly Pap smears, no screening for ovarian cancer, screening for chlamydia etc only in those at risk, and I think few doctors would insist on a pelvic exam before prescribing the pill (I just check BP and do a lot of talking).

    However, I sense that quite a few doctors still do a routine bimanual exam at visits for Pap smears. Certainly I was taught to do this in medical school. (I have stopped now.) I found this article a useful overview of the evidence: http://www.racgp.org.au/afp/200611/12512 , and another article by the same team offers some insights into doctors’ resistance to changing their behaviour in this area: http://www.racgp.org.au/afp/200806/25071 .

  34. cellculturequeen says:

    Are there any evidence-based recommendations for women using an IUD? The general advice seems to be an annual check-up, but what exactly is the point of this?
    (It confirms the IUD is still there, of course, but considering how much of a drama it was to get that thing in, I don’t believe I could use it without noticing.)

  35. cellculturequeen says:

    Oops. That was supposed to say: “LOSE it without noticing.”

  36. Harriet Hall says:

    @micheleinmichigan

    “my one concern about skipping the pelvic is that my mother died from uterine cancer.. I have no idea if that’s found in a pelvic exam, through symptoms or what symptoms, etc.”

    The Pap smear is what finds cancer in asymptomatic women, not the pelvic exam itself. Abnormal bleeding, especially post-menopausal, can be a symptom of uterine cancer and should be evaluated with endometrial sampling. That requires a pelvic exam, but again, it is not the exam itself that is useful in detecting cancer.

  37. Harriet Hall says:

    @cellculturequeen,

    “I don’t believe I could lose it without noticing.”

    It happens. You can learn to check yourself for its presence: there is usually a palpable string. If you are suddenly unable to find the string, then you can see your doctor. Sometimes the string retracts up into the uterus, requiring imaging procedures to confirm that it is still there.

  38. @ Harriet Hall, Thanks!

  39. Damn, can’t believe I fell for the spam link.

  40. Steve Packard says:

    “I think it’s still worth checking because plenty of women are the victims of rape or sexual assault and it might not be something that they will tell their doctor. There’s still too much shame associated with it still in our culture.

    On top of that, there are plenty of sexually active people that will lie and say they are not sexually active, again because of stigma and shame. And there’s really no good way for a doctor to tell those people apart from the ones who are truly celibate. This is probably most common among teenagers so maybe older adults can be taken at their word. “

    There are some women who I am quite sure are not sexually active, or rather I’d generally be very surprised if they were. I’m talking about some who are, for example, 80 years old, have been widowed for ten years, and literally leave their homes about twice a month, always with a family member driving them, not taking visitors, and possibly not even capable of having sex safely because of a heart condition.

    I used to live next door to a woman who never drove a car and from the time her husband died when she was 65 to the time she died in her late 80′s, she only left the house to go to her garden and the only time she left the yard was once a week when her son picked her up to take her to the doctor and the grocery store. Never had a social visitor who was not family.

    Do we really need to screen such individuals for sexually transmitted diseases each year? I mean, seriously.

    A person does not need to disclose whether or not they are sexually active. They could simply choose not to bother with being screened for sexually transmitted infections if they are not.

  41. cellculturequeen says:

    @Steve Packard:

    As far as I know, no one is forced to get those exams done, so… What exactly is your point?

  42. wannabeer says:

    Long-time lurker, rare caller. This post is timely. My mother was diagnosed at 79 with endometrial cancer this past November. A “huge” (per her surgeon) tumor which spilled out of the uterus, made its way into the cervix and started to change into a sarcoma. (It occurs to me it’s rarely good for you to be interesting to a pathologist — but a tumor that looks like two different ones but isn’t apparently is super cool). She hadn’t had any kind of pelvic examination since 1962 and certainly never had a Pap smear (which wouldn’t have detected this cancer anyway, I believe). I’d been refraining from saying, “I told you to go!” and the post makes me feel even better about my restraint. I still find it difficult to believe that this wouldn’t have been caught if she had, oh let’s say, tri-annual visits.

    Last week I had my annual pelvic, which I ordinarily hate but for obvious reasons was happy to schedule this time. Doc found a mobile mass and I have a pelvic ultrasound scheduled this week. I know it’s overwhelmingly likely not to be serious, but here I was thinking it was good to have early detection. Now I will worry instead about whether I’m being over-treated. Curse you and your science. (Not really).

  43. Harriet Hall says:

    wannabeer said “I still find it difficult to believe that this wouldn’t have been caught”

    But the real question is whether catching it earlier would have made a difference in the final outcome, or would only have extended the period during which she carried a diagnosis. Sometimes blissful ignorance improves quality of life.

  44. wannabeer says:

    Agreed Dr. Hall. And perhaps that’s correct. But what I’m hearing from the oncologist is that her best guess is that it started out as a “garden variety” endometrial cancer, hung around a while, and started turning into something more aggressive. Having just concluded “Emperor of All Maladies” (great book), I understand that the nature of the beast is to be, well, a beast, and that even a garden variety thing can be bad. But logic tells me in this case (which I concede is apparently quite rare), there was some opportunity to discover and treat before the change. I’m not arguing the central point that an annual is overkill. I’m just thinking that dispensing with it altogether until there are symptoms may not work either.

  45. Peter Lipson says:

    @Steve P

    Guidelines do not recommend yearly paps or STD screening for many groups, including women with 3 consecutive negative yearly paps.

    Chlamydia rates in young women are so high, and potential complications so severe, that screening makes sense based on a risk/benefit point of view, although the data are still sketchy as to what population may benefit the most. For example some studies have found (in certain countries) very low rates in rural populations compared to urban, and rates among young women are much higher than among women over 30.

  46. Harriet Hall says:

    Agreed, wannabeer,

    There are undoubtedly cases where earlier detection is beneficial, but we have no way of knowing which cases these will be, so we are torn between screening a lot of women unnecessarily (potentially causing greater harm overall), and screening no one (and occasionally missing a diagnosis). There is no easy answer, and what is right statistically for a large group may turn out to be the wrong choice for an individual. Medicine would be so much easier if we had crystal balls! :-) Reality is a bitch.

  47. khan says:

    I had to get the full crotch exam every year to get my BC pills. At age 30, DR said no more pills. So I stopped going.

  48. SuziQ says:

    Seems like it’s the doctor’s personal preference up here in Canada. I’ve had an annual exam every year for 9 years now in order to get a birth control perscription. Finally my doctor told me I could come in every two years because my tests always came back clean.

    Then she retired. Her replacement insists that I come in every year, and she won’t even give me a “grace” month of birth control in case I can’t get an appointment. Therefore, if I miss my annual exam for any reason, I risk an unwanted pregnancy and have to go to the trouble of figuring out another method of birth control.

    It’s like oral contraceptives are some kind of illicit substance. I swear, it would be easier and less uncomfortable for me to get a perscription for Percocets or medical marijuana.

  49. Daniel M says:

    Dr. Hall,

    This is way off topic, but I had a quick question for you. Do you know how much CAM and integrative medicine have infiltrated University of Washington’s medical school? I just got accepted there and was trying to do some research on the subject before I start in the fall. I know they used to have an integrative medicine center, but I can’t find anything current on it.

    I know you attended there and still lived in the state so I thought you might know. Thanks largely to the hard work of yourself and the other authors on this blog I’ll be starting medical school as a science-based medicine convert! Keep up the good work.

  50. Harriet Hall says:

    Daniel M,

    I don’t have any current contact with the University of Washington School of Medicine, but I did find this CAM Graduate Certificate program in the School of Nursing that is worrisome and that provides a link to Bastyr.
    http://nursing.uw.edu/academic-services/degree-programs/certificates/cam/complementary-and-alternative-medicine-cam-gradua

    Once you start school there, you can be our reporter on the scene; and if there is anything I can do to support you and help keep my alma mater from slipping further into quackedemia, let me know. I’m glad science-based medicine will have at least one representative there.

  51. Chris says:

    Daniel M, remember it is a big school full of lots of different personalities*. But I hope there is more good than bad. For a taste try downloading (or even watching) this conversation from This Week in Virology:
    http://www.virology.ws/2011/02/20/twiv-121-huskies-go-viral/

    * I live in the shadow of the university. Some of those personalities are my neighbors and parents of my kids’ classmates. It is an interesting place.

  52. Newcoaster says:

    As a Family Physician, I have long wondered about the ritual of the annual complete physical, which for women involves a pelvic and breast exam. As evidence has accumulated we have done away with the “routine” chest Xray, urine tests, and now most screening blood tests. My clinic nurses do the majority of PAP, pelvic and breast exams in our clinic, and they routinely have been doing chlamydia and gonorrhea swabs for reasons that escape me, other than “that’s how they were trained”.

    I certainly have been trying to steer patients away from the idea that if they come in to see me every year for a “once over”, all their health needs are being met. Older patients still have the idea that there is something magical about the annual exam. Of course, younger patients..men anyway…rarely see the doctor, so it is tempting to take advantage of their infrequent appearances to test for everything…evidence be damned.

    And yes, Harriet, I do a token listen to the heart and lungs because it is expected, not because I have ever diagnosed respiratory or cardiac disease that was unknown before I applied my stethoscope. I think it is one of the last hands on rituals of the doctor-patient relationship. When we lose these personal touches, we will lose the patient to the CAMsters.

  53. Imadgeine says:

    From these far flung British shores the routine annual exam really sounds like an income generation scheme for Gynaecologists. In UK we have routine smear tests , usually done by nurse in the general practitioners surgery – but not every year. Consultations with fully qualified OB/Gyns would happen when we complain of symptoms and the GP thinks we need an investigation.

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