Amir Qaseem, MD, PhD; Linda L. Humphrey, MD, MPH; Russell Harris, MD, MPH; Melissa Starkey, PhD; Thomas D. Denberg, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians *
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
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Disclosures: Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-0701. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Qaseem and Starkey: 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Humphrey: 3710 Southwest US Veterans Hospital Road, Portland, OR 97201.
Dr. Harris: 725 Martin Luther King Boulevard, Chapel Hill, NC 27599.
Dr. Denberg: PO Box 13727, Roanoke, VA 24036.
Author Contributions:Conception and design: A. Qaseem, L.L. Humphrey, T.D. Denberg.
Analysis and interpretation of the data: A. Qaseem, L.L. Humphrey, R. Harris, M. Starkey, T.D. Denberg.
Drafting of the article: A. Qaseem, R. Harris, M. Starkey, T.D. Denberg.
Critical revision for important intellectual content: A. Qaseem, L.L. Humphrey, R. Harris, M. Starkey, T.D. Denberg.
Final approval of the article: A. Qaseem, L.L. Humphrey, R. Harris, T.D. Denberg.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey.
Collection and assembly of data: A. Qaseem, R. Harris.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the utility of screening pelvic examination for the detection of pathology in asymptomatic, nonpregnant, adult women.
This guideline is based on a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. Evaluated outcomes include morbidity; mortality; and harms, including overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort. The target audience for this guideline includes all clinicians, and the target patient population includes asymptomatic, nonpregnant, adult women. This guideline grades the evidence and recommendations using the ACP's clinical practice guidelines grading system.
ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women (strong recommendation, moderate-quality evidence).
Table. The American College of Physicians' Guideline Grading System*
Summary of the American College of Physicians guideline on screening pelvic examination in adult women.
HPV = human papillomavirus.
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July 1, 2014
I'm not sure what the impetus for this study was, but it appears to follow from the societal conditioning that women's bodies are inherently more private than men's. We do back flips trying to find a female chaperone for pelvic exams, but don't seem to care who is in the room for male GU exams, rectal exams, or Foley insertions. Even for symptomatic patients, we treat women differently. For the woman with UTI symptoms, do you do a pelvic? Most do not. They send a urine and treat. How about for a guy who says it burns when he pees? Everyone does a GU exam. We have a bias based on unrecognized societal conditioning. The question is, are we harming women by holding back on exams, or, are we harming men due to our casual indifference to their modesty, and inflicting "pain, discomfort, fear, anxiety, or embarrassment" as the study says we're doing to women? Because we always examine a man's genitals at a routine physical.So maybe we should not do scrotal exams at physicals, because men feel anxiety and embarrassment too, especially since testicular cancer is almost NEVER found primarily by a doc, but usually by the patient. Digital rectal exams are FAR more personally invasive (most female patients tolerate a bimanual, but balk at a rectal), and carry a real risk of further testing from false positives, so using the logic in this article, they should not be done either. While we're at it, maybe we shouldn't listen to the heart, or palpate the abdomen, or look at any skin during a screening physical,as we're unlikely to find a problem, based on percentages. Because these exams also cause anxiety and have the potential for embarrassment. Sarcasm aside, perhaps this is a good question: Is it time to abandon the routine office exam, and only do an exam for patients with symptoms?
Jesse Ethridge, MD, Fellow American College of OB/GYN
Mississippi Baptist Medical Center
A step backward
Having been in private practice 26 years, I am disappointed by this new recommendation by the American College of Physicians. Isn't our whole purpose to screen patients and promote wellness? What do you say to the asymptomatic 22 year old nurse I recently saw who had an 8cm endometrioma detected on pelvic exam? What about the 62 year old asymptomatic woman who had a 9cm pelvic mass that was a tumor of borderline malignant potential? Isn't it our job find these problems? Are we just going to wait until they have symptoms? Really?? I guess that's just fine unless it is YOUR mother, wife, daughter or sister. Of course most pelvic exams in asymptomatic women are normal, but I am so concerned about what we are going to miss.
July 7, 2014
Speaking as a health care consumer
While I appreciate the sentiments expressed so far, all I can say is "Hallelujah!" Oh, happy day to be liberated from the constant invasion. This one, along with the one on mammograms, sets me free from being subjected to painful, horrible, awful exams no matter how tender the touch. It's just gruesome, depressing, and the unbelievable pressure to conform is unconscionable. I've been dehumanized like this since I was 15 years old--every freaking year. Forty years later, I'm claiming my body for my own. And if men feel the same way about their bodies, then speak up! Now if only there'd be a study of decades' worth of those colonoscopies in asymptomatic 50-year olds. I've resisted that one so far and will continue to do so.
Carol Bates, MD and Jennifer Potter, MD
Beth Israel Deaconess Medical Center
July 8, 2014
Digital exam before Pap to minimize discomfort
We greatly appreciate this guideline and the associated evidence review, but would argue that the discomfort associated with pelvic examinations has not been sufficiently characterized to determine the degree to which the speculum or the bimanual exam is the primary source. Traditional teaching has recommended performing the speculum examination first, without any lubricant other than water; one might imagine this to be the most uncomfortable aspect of a sequential examination. We now know that water-based lubricant does not interfere with cytological assessment or with assessment for vaginal or cervical infection. Speculum examinations may be uncomfortable at insertion but repositioning and excessive spreading of the speculum in order to visualize the cervix can also be painful. It is therefore our practice to perform a lubricated digital examination before inserting the speculum in order both to lubricate the introitus and to identify the location of the cervix. It is much easier to direct the speculum accurately if one already knows whether the cervix is near the introitus, deep in the vault, or on the high anterior vaginal wall. Each of these cervical locations can make it challenging to visualize the cervix. While we agree with the desire to achieve the most patient-centered examination possible when obtaining a cytological sample, we believe this is best achieved after a preceding digital examination. (1) We agree that there is no other indication for bimanual examination in an asymptomatic patient.We do worry about our trainees’ ability and confidence to assess pelvic structures when examinations are indicated to assess symptoms, but we cannot ethically justify intrusive examinations without indication. 1. Bates CK, Carroll N, Potter J. The Challenging Pelvic Examination. JGIM 2011;26:651-7.
Samuel Metz, MD, Debra Gussman, MD
July 15, 2014
Both the American College of Physicians (1) and American College of Obstetricians and Gynecologists (2) agree that annual pelvic exams for asymptomatic women offer little intrinsic value. However, both would acknowledge that annual encounters to discuss safe sex, sexually transmitted diseases, birth control, urinary tract infections, and pre-pregnancy counseling offer high value. Unfortunately, insurance companies disagree. Most readily pay for annual exams that lack clinical value but withhold payment for discussions providing high value.
As a consequence, women seeking counsel from their gynecologists to discuss safe sex, etc. must endure an unwanted, unindicated, and uncomfortable procedure or pay for the visit out of pocket. There is no escaping the exam: charging for an unperformed procedure constitutes fraud.
It is not physicians or patients who perpetuate inappropriate pelvic exams. It is insurance administrators. To correct this, we must alter the practice of insurance companies whose payment policies contradict best clinical practices.
1. Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, for the Clinical Guidelines Committee of the American College of Physicians. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:67-72.
2. American College of Obstetricians and Gynecologists. ACOG Practice Advisory on Annual Pelvic Examination Recommendations. June 30, 2014. http://www.acog.org/About-ACOG/News-Room/College-Statements-and-Advisories/2014/ACOG-Practice-Advisory-on-Annual-Pelvic-Examination-Recommendations. Accessed July 14th, 2014.
Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD, for the Clinical Guidelines Committee of the American College of Physicians. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. ;161:67–72. doi: 10.7326/M14-0701
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Published: Ann Intern Med. 2014;161(1):67-72.
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