By Genevra Pittman
NEW YORK (Reuters Health) - Many doctors give women pelvic exams when they're not called for by guidelines, for example to screen for ovarian cancer or before prescribing birth control pills, according to a new study.
That's worrisome, researchers said, not only because the exams are invasive, but because they come with a risk of false positives that can lead to more unnecessary tests and procedures.
"Women should know that screening tests come with both harms and benefits, and the pelvic exam is not an exception to that," said Analia Stormo, from the Centers for Disease Control and Prevention in Atlanta, who led the study.
"We need to provide physicians with more of a clear message of when it's appropriate to use pelvic exams," she told Reuters Health.
The screening exams involve looking at the vagina and cervix and doing a manual exam with one hand inside the vagina and one outside to feel the uterus and ovaries.
Women have gotten in the habit of getting a pelvic exam every year, the researchers said, and doctors are accustomed to giving them -- but it's unclear if they serve any real purpose in women without any pelvic pain or signs of infection.
Stormo and her colleagues surveyed 1,250 doctors, including obstetricians and gynecologists, family doctors and internists on how often they performed pelvic exams to screen for cancer or sexually transmitted infections (STIs), as a requirement before prescribing birth control pills or as part of a typical physical or "well-woman" visit.
OB/GYNs were the most likely to say they routinely performed pelvic exams in each of those cases, but the majority of family and general doctors also did pelvic exams for every indication in question.
While the most doctors said they used the exams as part of a general well-woman visit, 95 percent of OB/GYNs and 55 percent of general doctors also screened for ovarian cancer using pelvic exams, and between 68 and 92 percent of those doctors used them to screen for STIs or as a requirement before prescribing birth control.
Internists were the least likely to perform pelvic exams for each scenario.
Dr. Mona Saraiya, who also worked on the study, said there's no need to do a full pelvic exam to screen for STIs -- taking a swab or doing a urine test is enough. The researchers also said there isn't any evidence that screening for ovarian cancer with a pelvic exam prevents women from dying of the disease, or that it's needed before women go on birth control.
As part of a well-woman exam, its usefulness isn't clear one way or the other.
No matter how it's used, a pelvic exam can lead to so-called false alarms and overdiagnosis, when doctors find disease that would never have caused any symptoms but is treated nonetheless.
It's also a very personal procedure. "It's not like palpating your stomach," Saraiya said.
"If a pelvic exam is considered so sensitive that it deters women from actually coming in for hormonal contraceptives or STI testing, that's a harm," she told Reuters Health.
PELVIC EXAMS TAKEN FOR GRANTED
Dr. George Sawaya, from the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, said there simply hasn't been much attention paid to the possible benefits and harms of pelvic exams, and that more research and thought is needed to better determine and balance those.
"Any woman would say that certainly a major component of her visit to the gynecologist includes...a pelvic examination. This is something they just take from granted in many ways," said Sawaya, who wrote a commentary accompanying the study in the Archives of Internal Medicine.
Organizations including the American College of Obstetricians and Gynecologists recommended the pelvic exam as part of routine check-ups in most adult women, but other guidelines are inconsistent, adding to the confusion, according to Saraiya.
Researchers agreed that women shouldn't hesitate to have a conversation with their doctor about why they're getting a pelvic exam -- or any other screening test, for that matter.
And Saraiya emphasized that evidence-backed procedures and counseling, such as asking women about instances of domestic violence and checking their histories for specific warning signs for disease, should be top priorities during time-strapped visits.
"I think we just have to have some thoughtfulness about why we do (pelvic exams) and whether there's good evidence that the net benefit is substantial," Sawaya told Reuters Health.
When it comes to screening for ovarian cancer in particular, "that's probably a very misguided use of this examination," he said.
"I think it's important to understand that nothing is harmless," Sawaya concluded. "We're not just trying to maximize benefits, we're trying to minimize harms. It's a two-way street."
SOURCE: http://bit.ly/ueoIZG Archives of Internal Medicine, online December 12, 2011.