The American College of Physicians created controversy and discord with the American College of Obstetrics and Gynecology by stating that women without symptoms of pelvic disease and of average risk” do not benefit from pelvic exams as part of routine care.” This recommendation received major media coverage. ACP panelist Russell Harris MD of the University of North Carolina in Chapel Hill in an interview with the University of Pennsylvania on line journal MedPage Today added further confusion to the recommendations by saying that “Our guidelines really have to do with women who do not have symptoms, who do not have a discharge or bleeding or pain. Our guidelines talk about screening of asymptomatic women who are not pregnant. Those women simply don’t need the exam. It’s not something that is useful for them.” The article goes on to say that “the guideline also does not apply to women who are due for cervical cancer screening.”
The concern is that the exam is intrusive in a private area and most findings lead to evaluations that lead one down an investigative path that is expensive, invasive and studies show very little yield in terms of finding preventable disease. This is based on the groups’ review of 52 published studies between 1946 and 2014.
Once again organized medicine has shown a way to be confusing, divisive and contributing to the appearance that the right hand does not know what the left hand is doing. The ACP and the American College of Obstetrics and Gynecology should have discussed this issue and released a joint recommendation which makes sense. The ACP guidelines suggest we should be visually inspecting the cervix which requires a speculum exam and using cervical swabs for cancer and or human apillomavirus. How much extra time and cost is involved if the clinician with the patient’s pre approval digitally and manually palpates the uterus, ovaries and rectum for the presence of unsuspected anatomical abnormalities? Is this, in fact, another effort by the American College of Physicians, and the American Board of Internal Medicine, to dumb-down and accelerate the training of future physicians? If we do not perform a certain number of pelvic exams on normal individuals how is one going to recognize an abnormal exam? This is the same type of short sighted thinking that led to the Institute of Medicine and US Preventive Task Force recommending that we do not teach women how to perform breast self -examination to detect breast irregularities? It reminds me of the recommendations years ago to stop doing chest x rays on smokers for the detection of lung disease and lung cancer because it was low yield and not cost effective. Funny how 20 years later the recommendations now call for screening low dose CT Scans of the Chest on smokers 55 years or older who have been smoking for many years.
I will continue to discuss the issue of a pelvic exam with my patients and suggest they discuss it with their gynecologist as well. I believe that 15 -20 years down the road the guidelines will once again insist on examinations of the uterus and ovaries when the politics of the times is not solely set on reducing health care costs! Hopefully those new suggestions will not be fueled by an increase in advanced gynecological cancer due to 20 years of no one examining their patients.
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