Seeing your doctor for regular medical check-ups will help you stay healthy and pick up early warning signs of disease or illness.
These check-ups cover examinations and tests such as listening to the heart, lungs, and measuring blood pressure, and blood tests appropriate for the person’s age and risk factors. They also include important discussions and updates on menstrual periods, pregnancy, and sexual history, current medications, diet and exercise, vaccinations, use of alcohol and tobacco, past and current health issues.
A pelvic exam is also a common part of a woman’s annual wellness visit. Obstetrician/gynaecologists and other primary care physicians have performed pelvic exams on women regularly for several decades. Now some physician groups have expressed differing opinions as to whether pelvic exams should be included in a woman’s wellness visit.
First, What’s a Pelvic Exam?
You may have had many in your life, but did you know that the exam has three distinct parts to it?
- During the first part of the pelvic exam, the doctor checks the external area of the vulva for anything that looks abnormal
- Next, the doctor inserts an instrument called a speculum into the vagina to inspect the vagina and cervix which is the lower, narrow end of the uterus that protrudes into the vagina. When a Pap test is required it will be performed during this time. Historically called a Pap smear, the Pap test involves the removal of a sample of cells from your cervix with a brush. This sample is then sent to a laboratory where it is viewed under a microscope to see if the cells are abnormal or cancerous
- Lastly, the doctor checks the internal organs by inserting gloved fingers into the vagina while gently pressing on the abdomen from the outside with the other hand. This part is called a “bimanual” (meaning “two handed”) exam, and is how the doctor may be able to feel irregularities in the ovaries, fallopian tubes, and uterus
What’s the Debate about Getting a Pelvic Exam?
In the summer of 2014, the American College of Physicians (ACP) updated a clinical practice guideline that may change how and when pelvic exams are performed. This new guideline recommends against performing screening pelvic examinations in asymptomatic (having no symptoms), non-pregnant, adult women. This would mean that adult women who have no symptoms of gynaecologic disease and are both considered to be at average or low risk for developing gynaecological cancers and not pregnant, do not need to undergo a pelvic exam during their annual wellness visits.
The ACP guidelines in effect, recommend against the speculum and bimanual part of the exam for most women and don’t address the other parts of the exam or visit, such as a Pap smear for cervical cancer screenings. Those for whom pelvic exams are still recommended are women with vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.
The reason for this change is that the ACP reviewed studies from the past 6 decades to see what works and what doesn’t about giving routine pelvic exams to women. The review found that pelvic exams did not help to find treatable diseases in a subset of non-pregnant, relatively healthy women who had no gynaecologic symptoms. The review also found that pelvic exams caused discomfort, fear, anxiety, and false positive results (which is when a problem is suspected based on the exam, but actually turns out to be normal after further testing). The exams were also found to create extra costs, due to follow-up tests and more medical visits that are not necessary. The ACP concluded that screening pelvic examinations in asymptomatic, non-pregnant women are not necessary. This change is part of a movement in healthcare to institute high-value care that is based on medical evidence.
The American Congress of Obstetricians and Gynecologists (ACOG) recommendations differ from the ACP recommendation. In official statements, ACOG recommends annual pelvic exams for all women aged 21 years and older—even those who have no symptoms and are at low risk for gynaecological diseases—as part of a well-woman visit.
ACOG also asserts that the pelvic exam may be as important as any other part of the physical exam given during a wellness visit. Similar to an exam that may assess one’s ears, eyes, throat, heart, and lungs, the pelvic exam assesses the health of the vulva, vagina, uterus, cervix, fallopian tubes, and ovaries. Your female reproductive organs are thus treated as any other structure in your body, which may need examination.
The Royal Australian and New Zealand College of Gynaecologists and Obstetricians (RANZCOG) have guidelines for examinations and procedures. The latest update states that if a pelvic exam is indicated doctors should ensure that:
- An adequate explanation is provided about the nature of an examination and the information that it will provide;
- You have the opportunity to decline the examination;
- Your permission is obtained;
- Privacy is provided for disrobing;
- Suitable cover is provided during the examination, for example, gown or cover sheet; and
- A doctor should explore with the patient the value of a chaperone being present during the examination and or allow the patient to bring a support person of their choice.
- They always wear gloves when examining genitals or conducting internal examinations
- They are mindful of the patient and cease an examination when consent is uncertain, has been refused or has been withdrawn
- The patient must be made aware in advance of the presence of medical students and the right to decline their attendance at any examination.
- It may be appropriate to delay examination until a follow-up appointment.
Discuss with Your Doctor
If you have symptoms such as vaginal discharge, bleeding, pain or discomfort, or problems with abdominal bloating, a pelvic exam is advised and important. You should discuss these symptoms or any other symptoms you may have with your doctor during your visit. If you are truly asymptomatic, you may want to discuss the risks and benefits of the pelvic exam with your doctor. There are a few possible factors and questions to consider.
Some women have strong emotions about getting a pelvic exam, such as anxiety, embarrassment, or wanting to avoid wellness visits and pelvic exams.
Ask yourself: How do you generally feel about your exam? Is the discomfort of it acceptable to you or not? Have you discussed your feelings about it with your doctor? Do you think that might help?
There are important asymptomatic conditions a pelvic exam could help to uncover, such as fibroids, cysts, genital warts, or other STDs.
Ask yourself: Would you feel at ease skipping a pelvic exam even if there are certain health issues that the exam may help find? Are you more anxious about the exam itself than the issues the exam may uncover?
Once you’ve assessed your own feelings and thoughts on the matter, you may want to speak with your doctor. Here are some things you can ask at the start of your next wellness visit:
- Do you think all women my age should get a yearly pelvic exam? Where do you stand on the issue?
- Are you performing the exams annually? If so, under what circumstances?
- Do you think I fall into the asymptomatic group? If so, what makes you think so?
- I don’t want to miss anything that might cause a health problem down the road. Can we review the reasons for having the exam?
Gary Comstock, MD, is a Field Medical Director on the Women’s and Men’s Health Team at Pfizer.