Published Jun 28, 2014, EveryDay Health
The American College of Physicians (the group that represents INTERNISTS, not GYNECOLOGISTS) published a recommendation this week stating that non-pregnant women who do not have specific complaints need not have a gynecologic exam.
Before you scream ‘WOO-HOO” and start the celebration, I need to point out a few flaws in their thinking.
No Pelvic Complaint Does Not Equal No Pelvic Problem
Let’s start with the “no complaint” part
Studies have shown that the majority of women who have conditions such as urinary incontinence, fecal incontinence, vaginal odor, vaginal dryness, unusual discharge, and vulvar discomfort do not mention it to their doctor, either out of embarrassment or because they think involuntary loss of urine and painful sex are “normal” parts of aging. Studies also show that the majority of doctors do not ask if these symptoms exist, and more often than not, these conditions go untreated. So much for no complaints.
Many conditions don’t have symptoms
Most women with growing fibroids, pelvic infections that can lead to infertility, ovarian cysts or a myriad of other pelvic conditions do not have symptoms, but early diagnose can make a big difference when it comes to avoiding problems down the road. Just a few months ago I saw a 55-year-old woman who had not seen a gynecologist for years. Her internist told her that after a hysterectomy a pelvic exam was unnecessary. Since she had “no complaints” her doctor did not put a speculum in or look in her vagina at her annual exam.
Eventually, she did have a complaint: a bloody vaginal discharge. She came to me and a 15-second speculum exam detected what turned out to be a Stage 4 vaginal cancer. These things don’t turn up overnight, and a vaginal exam long before it became symptomatic would have detected her problem when it was early and treatable.
How to Avoid Potential Harms of Pelvic Exams
The obvious question is, “What’s the harm in performing an annual speculum and bimanual pelvic exam?” Here are three, according to The American College of Physicians:
Pelvic exams are embarrassing
For whom? If the doctor is embarrassed, the patient will be embarrassed. Not to mention, rectal exams are embarrassing. Testicular exams are embarrassing. Should those be omitted as well? This propagates and validates that many women’s health concerns are taboo topics. Shh! Don’t talk about your vaginal odor. Don’t talk about your sexual concerns. Don’t talk about your incontinence. Not even to your doctor. If every other body part is examined but the genitals, it sends a clear message that the pelvis, vagina and vulva are not part of the regular comprehensive physical. The pelvic exam should be normalized, not marginalized.
Pelvic exams are painful
The article reports that up to 60 percent of women said pelvic exams were painful. 60 percent! One has to wonder why the majority of the patients in the study experienced pain. Was the person inserting the speculum inexperienced? Did he or she use a jumbo speculum? (One size does not fit all!) Maybe some exams were painful because the woman had terrible vaginal dryness that she forgot to “complain about.” A pelvic exam should never be painful, and if it is, it may indicate a problem.
A pelvic exam takes time
Yes it does. At least one minute. So does listening to a heart, or doing a breast exam. I am guessing my patient with vaginal cancer would have been glad to put up with one minute of embarrassment instead of undergoing cancer treatments and fighting for her life.
Gynecologists Still Recommend a Yearly Pelvic Exam
The American Congress of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic exam, even in a non-pap test year. To be fair, many internists are totally comfortable doing a pelvic exam and are eager to address many of the issues I described above. Just last week I gave a lecture to a group of internists who wanted to learn more about evaluating and treating vulvar and vaginal conditions. The real message is, there is value in an annual exam, but it depends on who does it. So take your pelvis to a doctor (or advanced practice nurse) who is interested, competent, and not embarrassed.