The field of medicine has a funny way of contradicting itself. Not that it’s on purpose, mind you. Thanks to rapid-fire advances in technology and new research discoveries, medicine is in a constant state of flux, always evolving.
Think about it…20 years ago, fat was the dietary demon to avoid at all cost. Now, further research shows some fats are actually good for us and sugar has been deemed the new enemy.
In 2002, the Women’s Health Initiative study, a 15-year investigation into the health of postmenopausal women, was halted three years early because a preliminary review of data revealed that women taking both estrogen and progestin had a higher rate of heart disease, stroke, and breast cancer. This all came as quite a shock to the medical community and public. After all, doctors had been prescribing the very same hormones to women for long periods of time to treat menopausal symptoms and because it was thought that hormone replacement therapy protected women against heart disease.
Now, there’s a new curve ball being thrown at a decades-long practice in women’s health. The American College of Physicians (ACP) released new evidence-based guidelines this month recommending against routine pelvic exams in adult, asymptomatic, non-pregnant women at average risk for cancer (July 1, Annals of Internal Medicine). The authors, who did a systematic review of 68 years’ worth of published literature, state that the “harms of screening pelvic examination outweigh any demonstrated benefits” – more specifically that pelvic exams “rarely detect important diseases or reduce mortality,” and can cause “pain, discomfort, fear, anxiety, or embarrassment” in women.
The authors also state that routine pelvic exams “lead to unnecessary, invasive, and potentially harmful diagnostic procedures,” driving up health care costs. That’s no small matter, considering that, preventive gynecologic services cost the U.S. health care system an estimated $2.6 billion each year, according to the ACP.
And so another battle of “to support or not support” in women’s health is underway!
“The gynecological exam, or ‘well-woman exam,’ is an annual opportunity for women to pursue issues relating to their reproductive health, sexual function, and pelvic anatomy,” said Peter Gearhart, MD, of Penn Ob/Gyn & Midwifery Care at Pennsylvania Hospital. “It is a forum for patient-physician discussions relating to everything from health education, contraceptive counseling, and pelvic organ function, to screening for sexually-transmitted infections and urinary incontinence. This isn’t the first time guidelines have been altered, and I’m sure it won’t be the last.”
For example, adds Gearhart, traditionally, the pelvic exam included an annual Pap smear to screen for cervical cancer. “Due to advances in technology which led to the discovery that the human papillomavirus (HPV) causes cervical cancer and the development of a vaccine, annual pap tests are no longer required,” he said.
The American Cancer Society now recommends pap testing every three years for women ages 21-65. Routine cervical cancer screening for women under 21 and over 65 is no longer recommended and women ages 30-65 can have extended, five-year screening intervals if they undergo a combined screening or pap testing and HPV testing.
So what about cervical cancer? The new ACP guidelines state that when screening for cervical cancer, the recommended examination should be limited to only visual inspection of the cervix and cervical swabs for cancer and – when necessary – for HPV. The ACP also found in their review that the accuracy of diagnosing infections or detecting gynecological cancer via a pelvic exam is low.
“Physicians don’t need to perform a pelvic exam to detect sexually transmitted infections,” said Gearhart. “STIs like gonorrhea or chlamydia are detected by urine tests and vaginal swabs instead. However, any woman who presents with pain and other symptoms such as abnormal bleeding or vaginal discharge, sexual dysfunction or urinary problems, should still undergo a pelvic exam,” – a stance the ACP still recommends. “Patients with no risk factors should be given the opportunity to accept or decline a pelvic exam,” added Gearhart. “Some of them may derive a lot of reassurance from having a ‘normal’ pelvic exam.”
“There are many reasons a women might need to have pelvic exam and clearly, there are times when a pelvic exam is not necessary,” said Gearhart. “However, the decision to perform a pelvic exam is one that should ultimately be made between each patient and her physician – and not dictated by formal guidelines.”