The pelvic examination put to the test

 

MEDICAL MATTERS:Benefits of an invasive procedure queried

‘ROUTINE GYNAECOLOGICAL examinations are bad medicine.” This must sound like music to the ears of women of all ages, who, by and large, dread the invasive aspects of having a cervical smear carried out or of having to endure an internal examination by a doctor.

Well it was the subject of a blog earlier this year by British Medical Journal columnistDes Spence. A London GP, he asks: “Why do we continue with these invasive, unscientific, unpleasant and illogical examinations?” He says he is unable to find definitive information on the value of pelvic examination from evidence-based websites, and so his opinions are backed up by a more generalised search.

There are a number of different elements to pelvic examination, not all of which are carried out on every occasion. First there is the “bimanual” examination, in which the doctor places one hand on the lower tummy and places digits from the other in the woman’s vagina. It’s the best way to check for any growths in the pelvis; in particular an enlargement of an ovary may be palpable. Next is the insertion of a speculum, which helps visualise the neck of the womb (cervix) and is commonly used when taking a cervical smear. As well as smears doctors sometimes take swabs from high up in the vagina if a discharge is present or there is some other indication of local infection.

Spence is not impressed by the evidence he found for bimanual examination. He notes that in gynaecology patients under general anaesthesia, one in three masses was missed, suggesting that if the results were extrapolated into a conscious population there is a high risk of false positive and false negative outcomes. As for the use of a speculum, he says “this examination clearly has a role when examining the cervix or removing a retained tampon”. But he found little evidence for their use when taking a swab. In his opinion, a low vaginal swab is a logical alternative and does not require the use of a speculum.

Australian GPs Rebecca Stewart and Jill Thistlethwaite published a paper in 2006, titled Routine pelvic examination in asymptomatic women – Exploring the evidence. Here are their recommendations:

* There is no evidence to support the necessity for pelvic examination of asymptomatic women taking hormone therapy or attending for a sexual health check.

* Pelvic examinations may be performed at the time of routine Pap (cervical smear) tests to aid in technical issues with the smear itself, but are not recommended for screening purposes.

* Pelvic examination at a woman’s request must be preceded by thorough gynaecological, medical and family history and after obtaining informed consent from the patient.

* The use of routine pelvic examination as screening for ovarian malignancy . . . cannot be justified due to the low prevalence of the disease and low sensitivity and specificity of the examination.

Writing in January 2011, researchers from the department of obstetrics and gynaecology, Columbia University Medical Center in New York found “the pelvic examination in asymptomatic women is not needed to screen for sexually transmitted infections, is not needed to initiate hormonal contraception, and is not beneficial for early detection of ovarian cancer”.

They also say “women’s avoidance of the healthcare system because of dislike of the pelvic examination directly interferes with public health goals of screening for Chlamydia to reduce infertility, reducing unintended pregnancy, and increasing appropriate cervical cancer screening coverage”.

Meanwhile, Thistlethwaite and Stewart say they found that explanations given to women about “normal” examinations were not fully understood and that many did not know what the pelvic examination was for.

So the next time your doctor suggests a gynae exam, ask them what they hope to diagnose and if there is another, less invasive way to settle the issue. While the evidence may not be there to label pelvic exams as “bad medicine”, it’s always good to ask “Why?”