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Skip The Stirrups: Doctors Rethink Yearly Pelvic Exams

First-year medical student Michelle Gentile assists her classmate Abbie Harts as she performs a pelvic exam on a volunteer at Northwestern University.
Joshua Lott
Reuters /Landov
First-year medical student Michelle Gentile assists her classmate Abbie Harts as she performs a pelvic exam on a volunteer at Northwestern University.

The American College of Physicians said Monday that it strongly recommends against annual pelvic exams for healthy, low-risk women.

In fact, the intrusive exams may do more harm than good for women who aren't pregnant or don't have signs of problems, a group of doctors wrote in the Annals of Internal Medicine.

When we heard that news here at Shots, we were happily surprised. No more stirrups? No more stripping down below the waist or hearing those dreaded words: "Now, you're going to feel a little pressure"?

Sounds great! I'm canceling my annual visit now.

Not so fast. Not all doctors agree about these new guidelines.

"This recommendation will be controversial," obstetrician-gynecologist Dr. George Sawaya wrote in an accompanying editorial with a colleague at the University of California, San Francisco. "Pelvic exams have long been considered a fundamental component of the well-woman visit."

Most pelvic exams are performed by OB-GYNs, and their society, the American College of Obstetricians and Gynecologists, still recommends annual pelvic exams for all women over age 21.

The agency concedes that "no evidence supports or refutes the annual pelvic examination ... for the asymptomatic, low-risk patient." And it recommends that each woman should discuss with her doctor whether a full exam is necessary, the agency writes on its website.

So what in the heck is going on? Should I get the pelvic exam this year?

To start figuring that out, we spoke with Dr. Ranit Mishori at Georgetown University School of Medicine, who wasn't involved in the new recommendation.

"When you go to the doctor's office and put your feet in the stirrups," she says, "the doctor uses the speculum to open the vagina and see the opening of the cervix. Then she takes a sample of the cervix."

This is called the Pap smear, and it screens for cervical cancer.

"There's no question that the Pap smear saves lives," Mishori says. "That part of the exam is not under question." (Women still need to get that exam every three to five years, the American Cancer Society recommends.)

It's what comes next in the exam that's up for debate.

After the Pap smear, the doctor puts two fingers up the vagina and the other hand on the outside of the stomach, Mishori says. The doctor then examines the ovaries and uterus with both hands.

This is called the bimanual exam, and for decades, doctors thought it could help detect ovarian cancer. But studies haven't shown that to be true.

"Every society, even ACOG, agrees that the pelvic exam can't find ovarian cancer in women who don't have symptoms," Mishori says. "There's really no evidence to support doing these exams on a regular basis in women who have no symptoms."

There's also no evidence that the bimanual exam cuts your risk of dying from ovarian cancer, the American College of Physicians concludes. On the other hand, false positives can lead to unnecessary tests and other procedures — not to mention the extra cost of seeing a doctor every year, instead of once every three to five years for a Pap smear, as is currently recommended.

If a woman is having symptoms or signs of trouble, such as bleeding, discharge, pain during sex or infertility, the doctors' association still recommends the pelvic exam.

Here's why the ACOG thinks the bimanual exam has value, even if scientific data don't exist to support it: What if you don't know you have symptoms or you think your symptom isn't serious enough to bring up with the doctor?

A doctor might discover hidden problems during the full pelvic exam, a representative for ACOG told Shots in an email.

For example, many women don't bring up urinary leakage with their doctors because it's embarrassing or they think it's a normal part of aging. But it's treatable, the rep says. And a gynecologist might be able to see signs of it during a full pelvic exam. If the woman skipped the pelvic exam, she might have missed the opportunity for treatment.

Copyright 2021 NPR. To see more, visit https://www.npr.org.

Michaeleen Doucleff, PhD, is a correspondent for NPR's Science Desk. For nearly a decade, she has been reporting for the radio and the web for NPR's global health outlet, Goats and Soda. Doucleff focuses on disease outbreaks, cross-cultural parenting, and women and children's health.