Rethinking the detested pelvic exam

July 31--For generations of women, the yearly pelvic exam was a detested but essential indignity, required to screen for cervical cancer and make sure other lady parts were in order.

Not anymore.

An independent expert panel that advises the government last month declared there isn't enough evidence to justify doing the invasive procedure annually on healthy women who aren't pregnant.

That's a big deal because the U.S. Preventive Services Task Force influences insurance coverage and medical practice. Its draft guidance lends credence to the controversial 2014 recommendation of the American College of Physicians, which represents 148,000 internists. The Philadelphia-based group concluded that screening pelvic exams -- 63 million of them a year -- not only didn't detect serious disease or reduce deaths, but caused discomfort, embarrassment, and often led to unnecessary diagnostic workups.

Even the American College of Obstetricians and Gynecologists, an ardent fan of the annual feet-in-stirrups checkup, has backed off. Four years ago, it said doctors should talk to patients about whether the exam is "appropriate" as part of a well-woman visit. In response to the task force's new advice, the group said in a statement it was considering whether "to update its guidance."

So this is great news for women, right?

Yes and no.

As with other routine screening practices -- think of breast and prostate cancers -- the evolving advice about a once-sacrosanct ritual comes with upsides and downsides. Even those who welcome the change say only time will tell how women adapt.

"One of the good things historically about pelvic exams is that they made women good health-care consumers," said family physician Giang T. Nguyen, head of student health services at the University of Pennsylvania. "I'm hopeful that women won't stop going to the doctor for preventive care just because they no longer need a pelvic exam."

Cynthia Pearson, executive director of the National Women's Health Network, a Washington-based consumer advocacy group, said: "We don't want women to get care or procedures they don't need. But we have generations of women who were taught to get their annual Pap smear and pelvic exam. Now that we're sliding away from that, will women's health suffer?"

Some still need it

For trained clinicians, the pelvic exam is a window on the alignment, size, and condition of reproductive organs.

For women, it's several minutes of unpleasant sensations in private places: The chilly blades of the speculum in the vagina. The spatula scraping the cervix (for the Pap smear). One gloved finger in the vagina and another in the rectum while a hand presses on the low belly.

Deep breath.

To be clear, experts agree that women still need the intimate examination if they are pregnant, or have symptoms of a gynecological problem such as bleeding, or are due for a Pap test. And an annual well-woman visit is still recommended.

But changes in technology, and the recent emphasis on "evidence-based medicine" -- meaning practices backed by research, not just opinion -- have led to the reevaluation of the automatic, annual, just-because pelvic exam.

Consider the venerable Pap smear. It was introduced in the 1940s, decades before the human papillomavirus (HPV) was identified as the cause of cervical cancer. Because a single scraping of cells often misses the ones turning abnormal, the Pap test was done annually to compensate.

Now, experts agree that routine testing should start later -- age 21 instead of 18 -- and be done less often if results are normal. (The guidance is complicated: Every three years from 21 to 29. Every three or five years from 30 to 65, depending on whether the Pap is combined with a DNA test for the virus.)

Nor is a pelvic exam needed to screen for sexually transmitted diseases. That can be done with urine, blood or self-administered cervical swab tests.

What about a pelvic peek before giving a birth control prescription?

"There was never any basis for that," said Craig Roberts, a physician assistant in the University of Wisconsin-Madison Health Service and longtime member of the American College Health Association. "That today is thought of as medieval."

Nguyen, at Penn, believes the pelvic exam visit deters tailored preventive care: "The time it takes for the patient to get undressed and have a chaperone and get the equipment for the pelvic exam is time we are not getting to know the patient by asking: 'How much do you drink? How many sex partners do you have? Are you using condoms and birth control?' "

Still, surveys find that many women, and more than a few doctors, cling to the old ways out of confusion or habit.

"I've seen women who insist on having a Pap smear because their moms told them that's what to do," Roberts said. "It's going to take a long time for that culture change, especially across generations."

Another reason for confusion is that pelvic exams have long been promoted as a preventive care catchall, a way to detect cancer -- of the ovaries, uterus, colon, and more -- plus a plethora of problems that includes herpes, vaginosis, fibroids, pelvic inflammatory disease, and pelvic floor dysfunction.

Even savvy, health-conscious young women can be forgiven for being fuzzy on the real purpose of the exams. University of Pennsylvania senior Ava Kikut of Burlington, Vt., for example, knew she should start getting them at age 21, the birthday she just marked, but wasn't sure why.

"The biggest reason would be ovarian cancer. That would be my guess," Kikut said.

Value without evidence?

To see what the evidence actually shows, the preventive services task force decided to do its first-ever review of studies of screening pelvic exams.

The published research, the panel concluded, is too scant and sketchy to assess the balance of benefits and risks.

"What we truly are saying is there is not enough evidence to say one way or the other," said task force member Ann E. Kurth, dean of the Yale School of Nursing. "We are calling for more research."

Gynecologists frame the debate differently.

"An absence of evidence isn't an absence of value. We all know there is value to laying on of hands," said ob-gyn Barbara Levy, the College of Obstetricians and Gynecologists' vice president for health policy. "In my 30 years of experience, women frequently don't complain of something, but they expect me to discover it. They may be embarrassed to talk about it. It's during the exam that I notice something and ask questions" about problems such as painful intercourse or incontinence.

One other factor has colored this controversy: money. In its 2014 report, the American College of Physicians said the estimated annual tab for pelvic exams, including unneeded ones, is $2.6 billion. Critics have suggested that ob-gyns have a financial interest in overdoing it.

But these days, that incentive is rather small, said Manny Oliverez, a medical billing blogger and CEO of Capture Billing and Consulting Inc., outside Washington. Commercial insurers reimburse for a routine annual physical, which includes a "well-woman exam" -- whether or not the pelvic exam or a Pap test is done. Medicare doesn't cover routine annual physicals, but it does pay separately for the pelvic exam and Pap test -- about $85.

"We deal with a lot of doctors," Oliverez said. "No one is billing it just to make an extra buck. It's work."

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