US panel finds insufficient evidence to support pelvic exams in asymptomatic women
There is insufficient evidence to assess the harms and benefits of using pelvic examinations to screen for gynaecologic conditions in asymptomatic nonpregnant adult women, according to a recommendation statement issued by the US Preventive Services Task Force (USPSTF).
Pelvic examination has been a mainstay in the evaluation for infectious diseases, vulvar disorders, benign uterine pathology (leiomyoma and endometriosis), and gynaecological malignancies (cervical and vaginal cancer). The task force, which is composed of an independent panel of medical experts, investigated whether there is evidence to support this practice in the primary care setting.
“We found that there was little evidence on the accuracy of screening pelvic examinations to detect various [gynaecological] conditions,” said Dr Kirsten Bibbins-Domingo, chairman of the USPSTF and an internist at the University of California, San Francisco, US. “The evidence is either lacking, of poor quality, or conflicting to assess the benefits and harms in this population.” [JAMA 2017;317:947-953]
Of all studies analysed, only four reported on ovarian cancer and four on various infectious diseases (2 on bacterial vaginosis, 1 on genital herpes, and 1 on trichomoniasis).
Similarly, there were no good- or fair-quality studies directly evaluating pelvic exam as a tool to improve the quality of life or to reduce disease-specific morbidity or mortality in asymptomatic women.
“This is not a recommendation against performing pelvic exams,” said Bibbins-Domingo. “At this time, there simply is not enough evidence to determine the benefits and harms of using pelvic exams to screen for conditions other than cervical cancer, chlamydia, and gonorrhoea.”
The recommendation applies to asymptomatic women 18 years of age and older who are at an average risk for gynaecologic conditions such as genital warts, trichomoniasis, uterine fibroids, and candidiasis, among others. It does not apply to screening for cervical cancer, gonorrhoea, and chlamydia, or any disorder for which the panel already recommends screening using Pap (Papanicolaou) smear, HPV test, and nucleic acid amplification tests, nor to pregnant women and adolescents.
“The recommendation of the task force appears reasonable,” said Dr Colleen P. McNicholas from the Washington University School of Medicine in St. Louis, Missouri, US and Dr Jeffrey Peipert from the Indiana University School of Medicine in Indianapolis, Indiana, US, in an editorial. However, despite the insufficiency of evidence to support or refute annual pelvic exams in asymptomatic women, it is not clear if it is time to abandon the procedure, they added. [JAMA 2017;317:910-911]
What is clear is that clinicians should not require asymptomatic women to undergo pelvic exam to obtain screening, counselling or health services. However, the procedure may be desirable in some asymptomatic cases, for example, in women who are considering intrauterine contraception or in those who seek reassurance regarding their gynaecological anatomy, said the editorialists.