No Need For Routine Pelvic Exams?

Woman Sitting with Tea CupThe 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.

Cervical Cancer Screening Guidelines – American College of Obstetricians and Gynecologists

Cervical Cancer Screening - Steve Reznick, M.D.On a routine basis my female patients, many of whom have undergone a total hysterectomy, ask me if they need to continue to have Pap smears annually. There has clearly been a great deal of confusion about who should get a Pap smears and when. This communication is an attempt to clear that up.

1. Women who have had a hysterectomy and removal of the cervix (total hysterectomy) and; have never had an abnormal Pap smear (graded a CIN 2 or higher – cervical intraepithelial neoplasia), do not require a Pap smear. If they are still getting them they should be discontinued and never restarted

2. Screening for cervical cancer by any modality should be discontinued after age 65 years in women with evidence of adequate negative prior screening ( 3 consecutive negativ pap smears with the most recent having been done within 5 years and no history of abnormal Pap smears graded CIN 2 or higher).

3. Cervical cancer screening should begin at age 21 years. Women younger than 21 years should not be screened regardless of the age of initiation of sexual activity or the presence of other behavior related risk factors.

4. Women aged 21-29 years should be tested with cervical cytology alone. Screening should be performed every 3 years

5. Women aged 30-65 should have “co testing with cytology and human papillomavirus (HPV) testing every 5 years.

6. In women aged 30-65 years, screening with Pal smear cytology every 3 years is acceptable. Annual screening is not preferred.

7. Women who have a history of cervical cancer, have HIV infection, are immunocompromised, or were exposed to diethylstilbestrol in utero should not follow these minimal routine screening guidelines.

8. Both liquid-based and conventional methods of cervical cytology collection are acceptable for screening.