The nation's second-largest physicians' organization said Monday that healthy women who are not pregnant do not need routine pelvic exams, a controversial recommendation based on its analysis that, on balance, the manual screening does more harm than good.
The American College of Physicians, which represents 137,000 internal medicine physicians and related specialists, said the diagnostic procedure causes some women discomfort, anxiety, pain and additional medical costs, and may keep some from seeing their doctors. Yet it does little to detect ovarian cancer or other disorders.
As a result, in a new guideline it issued Monday, the organization "recommends against performing screening pelvic examination in asymptomatic, non-pregnant, adult women" who have no elevated risk of cancer or other disease. Healthy women should continue to have Pap smears as recommended by their doctors, the group said. The guideline was published in the Annals of Internal Medicine, the ACP’s journal.
"The benefit hasn't been demonstrated, but the harm has," said Linda Humphrey, a professor of medicine at Oregon Health Sciences University, who helped write the new guidelines. "So when you look at the benefit-harm ratio, the harm kind of weighs out more than the benefits."
The American College of Obstetricians and Gynecologists, however, immediately responded in favor of doctors' continuing to perform routine pelvic screening on healthy women. That group "continues to firmly believe in the clinical value of pelvic examinations," it said in a statement, which help gynecologists turn up incontinence and sexual dysfunction, and allow them "to explain a patient's anatomy, reassure her of normalcy and answer her specific questions."
Barbara Levy, vice president for health policy at the organization, said that the pelvic exam provides a critical opportunity for women to raise concerns that, by themselves, might not send them in search of medical advice. "The pelvic exam, in our experience and in the opinion of our experts, has value," she said. " We see that value in being able recognize some of these embarrassing and sensitive issues that women often will not raise with us initially."
On its Web site, the National Ovarian Cancer Coalition recommends that "women age 18 and above should have a mandatory annual vaginal exam." But it also notes that "in most cases, ovarian cancer is not detected during routine pelvic exams, unless the doctor notes that the ovary is enlarged."
Humphrey said her group undertook a review of research on pelvic exams after the U.S. Preventive Services Task Force issued guidelines on screening for cervical cancer in 2012 but did not address pelvic exams. The review found that in two studies the "positive predictive value" of pelvic exams for ovarian cancer was less than 4 percent, and that 11 percent to 60 percent of women complained of pain or discomfort from the procedure. In one study, 174 abnormal screenings occurred among 2,000 healthy, average-risk women. Follow-up tests resulted in 31 surgeries, which found ovarian cancer in just two of the women.
Levy said, however, that those surgeries likely removed other abnormalities, such as fibroids and cysts, that could have caused problems later.
In the new guidelines, the American College of Physicians estimated the annual cost of preventive screenings, lab tests and radiologic services at $2.6 billion, a figure that Humphrey said could be reduced along with a substantial decline in routine pelvic exams. The document notes that a blood test is more sensitive at detecting ovarian cancer, though Levy said that test, known as "CA-125," is very imprecise.
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