Clinical Review

The pelvic exam revisited

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References

Interpreting the new USPSTF statement

We understand the USPSTF statement to mean that pelvic exams should not be abandoned, but rather should be individualized to each patient for her specific visit. We agree that for visits focused on counseling and routine screening in asymptomatic, nonpregnant women, pelvic exams likely will not increase the early detection and treatment of disease and more benefit likely would be derived by performing and discussing evidence-based and age-appropriate health services. A classic example would be for initiation or maintenance of oral contraception in an 18-year-old patient for whom an exam could cause unnecessary trauma, pain, or psychological distress leading to future avoidance or barriers to seeking health care. For long-acting reversible contraception placement, however, a pelvic exam clearly would be necessary for insertion of an intrauterine device.


Related article:
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Indications for pelvic examination

Remember that the pelvic examination has 3 distinct parts (and that not all parts need to be routinely conducted)3:

  • general inspection of the external genitalia and vulva
  • speculum examination and evaluation of the vagina and cervix
  • bimanual examination with possible rectovaginal examination in age-appropriate or symptomatic women.

According to the Well-Woman Task Force of the American College of Obstetricians and Gynecologists (ACOG), “For women 21 years and older, external exam may be performed annually and that inclusion of speculum examination, bimanual examination, or both in otherwise healthy women should be a shared, informed decision between patient and provider.”4

Indications for performing certain parts of the pelvic exam include4:

  • routine screening for cervical cancer (Pap test)
  • routine screening for gonorrhea, chlamydia infection, and other sexually transmitted infections
  • evaluation of abnormal vaginal discharge
  • evaluation of abnormal bleeding, pelvic pain, and pelvic floor disorders, such as prolapse, urinary incontinence, and accidental bowel leakage
  • evaluation of menopausal symptoms, such as dryness, dyspareunia, and the genitourinary syndrome of menopause
  • evaluation of women at increased risk for gynecologic malignancy, such as women with known hereditary breast–ovarian cancer syndromes.

In 2016, ACOG launched the Women’s Preventive Services Initiative (WPSI) in conjunction with the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services. In this 5-year collaboration, the agencies are endeavoring to review and update the recommendations for women’s preventive health care services, including well-woman visits, human papillomavirus testing, and contraception, among many others.5 Once the HRSA adopts these recommendations, women will be able to access comprehensive preventive health services without incurring any out-of-pocket expenses.

The pediatric and adolescent gynecologist perspective

Roshanak Mansouri Zinn, MD, and Rebekah L. Williams, MD, MS

No literature addresses the utility of screening pelvic examination in the pediatric and adolescent population. According to the American College of Obstetricians and Gynecologists Committee on Adolescent Health Care opinion on the initial reproductive health visit for screening and preventive reproductive health care (reaffirmed in 2016), a screening internal exam is not necessary, but an external genital exam may be indicated and may vary depending on the patient's concerns and prior clinical encounters.1 The American Academy of Pediatrics promotes annual screening external genital examination for all female patients as part of routine primary care, with internal examinations only as indicated.2

Age-appropriate pelvic examination for girls and nonsexually active adolescents usually is limited to an external genital exam to evaluate the anatomy and note the sexual maturity rating (Tanner stage), an important indicator of normal pubertal development. As in adults, the potential benefits of screening examination in this population include detection of benign gynecologic conditions (including vulvar skin conditions and abnormalities of hymenal or vaginal development). Additionally, early reproductive health visits are an important time for clinicians to build rapport with younger patients and to provide anticipatory education on menstruation, hygiene, and anatomy. These visits can destigmatize and demystify the pelvic examination and help young women seek care more appropriately and more comfortably if problems do arise.

Even when a pelvic exam is indicated, a patient's young age can give providers pause as to what type of exam to perform. Patients with vulvovaginal symptoms, abnormal vaginal bleeding, vaginal discharge, or pelvic or abdominal pain should receive complete evaluation with external genital examination. If external vaginal examination does not allow for complete assessment of the problem, the patient and provider can assess the likelihood of her tolerating an internal exam in the clinic versus undergoing vaginoscopy under sedation. Limited laboratory evaluation and transabdominal pelvic ultrasonography may provide sufficient information for appropriate clinical decision making and management without internal examination. If symptoms persist or do not respond to first-line treatment, an internal exam should be performed.

Patients of any age may experience anxiety or physical discomfort or may even delay or avoid seeking care because of fear of a pelvic exam. However, providers of reproductive health care for children and adolescents can offer early education, reassurance, and a more comfortable experience when pelvic examination is necessary in this population.

References

  1. American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. Committee Opinion No. 598: Committee on Adolescent Health Care: the initial reproductive health visit. Obstet Gynecol. 2014;123(5):1143-1147.
  2. Braverman PK, Breech L; Committee on Adolescence. American Academy of Pediatrics. Clinical report: gynecologic examination for adolescents in the pediatric office setting. Pediatrics. 2010;126(3):583-590.

Dr. Mansouri Zinn is Assistant Professor, Department of Women's Health, University of Texas at Austin.

Dr. Williams is Assistant Professor, Clinical Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis.

Developed in collaboration with the North American Society for Pediatric and Adolescent Gynecology


The authors report no financial relationships relevant to this article.

How will the USPSTF statement affect practice?

In an editorial in the Journal of the American Medical Association commenting on the USPSTF statement, McNicholas and Peipert stated, “Based on the recommendation from the task force, clinicians may ask whether the pelvic examination should be abandoned. The answer is not found in this recommendation statement, but instead in a renewed commitment to shared decision making.”6 We wholeheartedly agree with this statement. The health care provider and the patient should make the decision, taking into consideration the patient’s risk factors for gynecologic cancers and other conditions, her personal preferences, and her overall values.

This new USPSTF recommendation statement will not change how we currently practice, and the statement’s grade I rating should not impact insurance coverage for pelvic exams. Additionally, further research is needed to better elucidate the role of the pelvic exam at well-woman visits, with hopes of obtaining more precise guidelines from the USPSTF and ACOG.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

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