Rethinking the Gynecologic Examination
Am Fam Physician. 2003 Nov 1;68(9):1869-1872.
Current guidelines recommend initial Papanicolaou (Pap) tests three years after females become sexually active or at age 21 in sexually inactive women.1 My patients seem comfortable when I tell them they don’t need annual Pap smears. Yet, in teaching settings and among colleagues, I often hear the question, “If we’re not doing Paps, shouldn’t we be doing something?” Sexually transmitted infection screening, contraceptive counseling, safe-sex advice, and clinical breast examination are opportunities that are missed if patients don’t come to the office for annual Pap tests.
Many women of reproductive age seek health care if they need contraception (but do they really need physician visits for that?) or if they become pregnant. What should I tell my patients about Pap tests—see you in three years? Come back when you need help? Or, I want to see you annually, just not for a Pap test?
These questions often arise but without any obvious answer because the practice of medicine is an art as well as a science. The history of the annual physical examination for healthy women illuminates the “science” of medicine. The American Medical Association (AMA) first proposed an annual physical examination of healthy persons with a standard battery of tests in 1922.2 Over the years, the public embraced the proposal with 58 to 71 percent approval.3 But, in 1983, the AMA withdrew its support for the standard annual physical examination in favor of specific, clinically proven preventive services.4 Blood pressure screening and Pap tests for women are screening practices with proven effectiveness that save lives and reduce morbidity.
Other services may be effective but only when tailored to fit the patient—and this constitutes the “art” of medicine. It requires the development of a patient-physician relationship where information is conveyed in both directions and decisions are made cooperatively; the relationship is the foundation for virtually all interventions that are considered or enacted. So, to answer the question, “What part or parts of an ‘annual physical’ should be performed?,” both the science of preventive services and the art of medicine must be considered.
Blood pressure screening is the only component of the physical examination of asymptomatic women that has proven utility, while other components of the physical examination have not proved beneficial. For example, neither clinical breast examination alone nor counseling for breast self-examination have demonstrated effectiveness in reducing breast cancer mortality. The clinical breast examination alone has not been studied in randomized trials and, in several studies, breast self-examination counseling has not been shown to be effective in reducing breast cancer morbidity and mortality.5
The rectal or bimanual examination as part of the pelvic examination in healthy women has proved unnecessary in women younger than 50 years.6 In addition, clinical breast and pelvic examinations do not offer useful information in patients seeking hormonal contraception, and their requirement in this instance may reduce access to effective contraception.7 However, a careful physical examination can add to relationship building in clinical practice.
Pap tests have reduced cervical cancer morbidity and mortality, but controversy continues about which women should be tested at which frequency. Given that cervical cancer is caused by some strains of the human papillomavirus, which is transmitted sexually, Pap test recommendations should be tailored to the patient’s current and past sexual practices. For the woman who has never had an abnormal Pap smear and is monogamous or sexually inactive, a Pap test has limited yield. If she has had a hysterectomy for benign causes, a Pap test is not indicated.8,9
A number of studies support screening for sexually transmitted diseases. Three to 15 percent of asymptomatic women harbor Chlamydia.10 Screening for Chlamydia and gonorrhea has been effective in reducing morbidity in asymptomatic women at high risk.11,12
Checking cholesterol levels in women between the ages of 45 and 65 may be an effective form of screening for hyperlipidemia because the morbidity and mortality of atherosclerotic heart disease is significantly high, and effective preventive treatment is available. The best frequency of testing is not known, but screening more frequently than every five years is probably not warranted in women with normal lipid values.
Mammography has been successful in detecting early disease, but review of the current studies suggests that clinical effectiveness does not occur until ages 50 to 69 and with some controversy even then. Mammography may be as effective when undertaken every two years as every year. Screening for colon cancer with annual fecal occult blood testing or periodic sigmoidoscopy after age 50 has reduced morbidity and mortality, while chest radiography and urinalysis have not been effective cancer screens even in women at high risk. Screening asymptomatic women for diabetes or thyroid disease also has not proved effective.
The art of medicine requires exploring the psychosocial issues that cause women so much suffering: alcohol and drug use (8 to 20 percent of patients), tobacco use (12 to 30 percent), depression (lifetime expectancy of 20 percent), and domestic violence (12 to 23 percent). Screening for depression, alcohol and drug abuse, and domestic violence leads to earlier identification of patients with these problems but generally does not bring about a change in an asymptomatic woman’s behavior.
For example, one-time screening and counseling for tobacco abuse has a minor impact on smoking cessation—2.5 percent more women will stop smoking than if no advice is given (numbers needed to treat, 40).13 However, repeated messages about smoking cessation over long periods of time are associated with greater success.
The benefit of physician counseling in preventing smoking initiation has not been determined. However, school-based programs demonstrate a delay in initiating tobacco use, and physicians should support these programs in their communities.14 Supervised vigorous aerobic exercise programs improve smoking abstinence rates in women trying to quit smoking.15
A number of lifestyle modifications have been shown to improve women’s health: avoiding sun exposure, tobacco, and excess alcohol; regular dental visits; weight reduction achieved with physical activity and a healthy diet; unwanted pregnancy prevention; use of helmets and seat belts when riding or driving vehicles; and not operating a motor vehicle while under the influence of any substance, or while sleep deprived or distracted by cell telephones.
Unfortunately, physician promotion of these lifestyle changes rarely has an impact on a woman’s behavior. Knowledge alone does not change behavior. A significant physician-patient relationship is essential before a physician can be a change agent for lifestyle practices.
Good medicine is an art and a science, and relationships develop when care for an individual woman is given over time. The evidence-based medicine movement has affected the practice of medicine greatly, but it was never intended to, and never will, replace listening and caring for patients—the art of medicine. We can only apply our evidence-based science when we have developed a relationship with the patient in our office. Consequently, how we apply the evidence depends on the patient, and our experiences will range from a woman who values and receives reassurance from physical examinations to a woman who values an examination only if it is proved effective.
So what should the physician in this scenario do with the woman in her office? She could begin with the patient’s history by asking open-ended questions to discover who she is, what her behaviors are, and what she values, and then present and apply the ever-changing evidence.
Finally, the physician could offer options and negotiate a plan with an emphasis on a healthy lifestyle and effective testing. Among these options, she could include a Pap test and explain that having the test every three years or even less often, depending on the circumstances, usually is sufficient. If the patient has other screening or counseling issues that require more frequent visits, she should come in more often. When a physician does not have to do a pelvic examination, there is more time to spend on the patient’s other health concerns.
1. American Cancer Society. Cancer detection guidelines. 2003. Accessed online October 10, 2003, at: http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED.
2. American Medical Association. Periodic health examination: a manual for physicians. Chicago: American Medical Association, 1947.
3. Oboler SK, Prochazka AV, Gonzales R, Xu S, Anderson RJ. Public expectations and attitudes for annual physical examinations and testing. Ann Intern Med. 2002;136:6552–9.
4. American Medical Association. Medical evaluations of healthy persons. Council on Scientific Affairs. JAMA. 1983;249:1626–33.
5. Thomas DB, Gao DL, Ray RM, Wang WW, et al. Randomized trial of breast self-examination in Shanghai: final results. J Natl Cancer Inst Cancer Spectrum. 2002;94:1445–57.
6. Campbell KA, Shaughnessy AF. Diagnostic utility of the digital rectal examination as part of the routine pelvic examination. J Fam Pract. 1998;46:155–7.
7. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs. evidence. JAMA. 2001;285:2232–9.
8. Pearce KF, Haefner HK, Sarwar SF, Nolan TE. Cytopathological findings on vaginal Papanicolaou smears after hysterectomy for benign gynecological disease. N Engl J Med. 1996;335:1559–62.
9. Fox J, Remington P, Layde P, Klein G. The effect of hysterectomy on the risk of an abnormal screening Papanicolaou test result. Am J Obstet Gynecol. 1999;180:1104–9.
10. Turner CF, Rogers SM, Miller HG, et al. Untreated gonococcal and chlamydial infection in a probability sample of adults. JAMA. 2002;287:736–33.
11. Scholes D, Stergachis A, Heidrich F, Andrilla H, Holmes KK, Stamm W. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. 1996;334:1362–6.
12. Addiss DG, Vaughn ML, Ludka D, Pfister J, Davis JP. Decreased prevalence of Chlamydia trachomatis infection associated with a selective screening programme in family planning clinics in Wisconsin. Sex Transm Dis. 1993;20:28–34.
13. Cochrane Library 2001 Issue 2, Cochrane Tobacco Addiction Group 2000 Nov 9.
14. Kotteke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation intervention in medical practice: a meta-analysis of 39 controlled trials. JAMA. 1988;259:2882–9.
15. Marcus BH, Albrecht AE, King TK, et al. The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial. Arch Intern Med. 1999;159:1169.
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