USPSTF: Evidence Lacking on Pelvic Exams in Asymptomatic Women

July 06, 2016 03:30 pm Chris Crawford
[Gynecological exam table]

In 2010, physicians performed more than 60 million pelvic examinations in the United States. And although this is a common element of physical exams, it remains unclear whether performing screening pelvic examinations in asymptomatic women significantly affects disease morbidity or mortality.

On June 28, the U.S. Preventive Services Task Force (USPSTF) tackled this issue by posting a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening asymptomatic, nonpregnant adult women for gynecologic conditions using pelvic examination.

The task force found that current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic exams in these women -- an "I" statement.(www.uspreventiveservicestaskforce.org)

This is the first time the USPSTF has reviewed evidence on screening for a wide range of gynecologic conditions using pelvic examination.

Story highlights
  • On June 28, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement saying that current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women.
  • This is the first time the USPSTF has reviewed evidence on screening for a range of gynecologic conditions using the exam.
  • The USPSTF is providing an opportunity for public comment on this draft recommendation statement and accompanying draft evidence review until July 25.

The draft recommendation applies to asymptomatic women 18 and older who aren't at increased risk for various gynecologic conditions. Such conditions include infectious diseases such as bacterial vaginosis, candidiasis, genital warts, genital herpes, trichomoniasis and pelvic inflammatory disease, as well as other benign problems such as cervical polyps, endometriosis, ovarian cysts, dysfunction of the pelvic wall and floor, and uterine fibroids.

The USPSTF previously made separate recommendations on screening for cervical cancer, gonorrhea and chlamydia using tests that are often performed during a pelvic examination (e.g., Pap smear, HPV test and nucleic acid amplification tests).

Notes From the AAFP

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News the AAFP's Commission on Health of the Public and Science is currently reviewing this draft recommendation.

For context on the Academy's stance on this issue, in 2014, the AAFP endorsed a clinical practice guideline from the American College of Physicians that recommended against screening asymptomatic, nonpregnant women for pathology using pelvic examination, she said.

"As it stands, there isn't evidence for any benefit of screening pelvic exams in asymptomatic women," Frost said. "It isn't an effective screening strategy for ovarian or uterine cancer, and a pelvic exam isn't necessary to screen for gonorrhea or chlamydia.

"In a woman without symptoms, it's unclear what a pelvic exam might reveal that would reduce her morbidity or mortality."

Draft Recommendation Details

The USPSTF commissioned a systematic review to evaluate the evidence on the accuracy, benefits and potential harms of performing screening pelvic examination in asymptomatic, nonpregnant adult women.

The evidence review focused on gynecologic conditions that are commonly identified by physicians as reasons to perform a screening pelvic exam, including conditions where detection of early-stage disease is biologically and clinically plausible. The review also considered conditions for which another method of screening isn't already addressed in a current task force recommendation.

In addition, the review focused on studies that covered individual components of the pelvic examination, such as inspection of the external genitalia, urethral meatus, vaginal introitus and perianal region; speculum examination of the vagina and cervix; bimanual palpation of the uterus, cervix and adnexa; and rectovaginal examination of the posterior wall of the vagina.

The USPSTF found little evidence on the accuracy of screening pelvic exams to detect various conditions; four studies (n=26,432) reported on ovarian cancer, two studies (n=930) on bacterial vaginosis, one study (n=770) on genital herpes and one study (n=150) on trichomoniasis. All but one of the studies were of fair quality -- only the largest ovarian cancer trial was judged to be of good quality.

No good- or fair-quality studies directly evaluated the effectiveness of screening pelvic examinations in asymptomatic, nonpregnant women to improve quality of life, reduce disease-specific morbidity, or reduce disease-specific or all-cause mortality.

Specific research gaps task force members identified include a need for studies to evaluate the accuracy and effectiveness of screening pelvic examination to detect conditions other than ovarian cancer, bacterial vaginosis, genital herpes and trichomoniasis. Also lacking, said the USPSTF, are studies that address the harms of screening with pelvic examination (including quantified psychological harms) in asymptomatic women in primary care settings.

The task force also called for studies to evaluate and quantify harms of these pelvic exams, as well as studies to gauge the potential effectiveness of risk assessment tools to determine which women might benefit most from screening pelvic examinations.

Furthermore, said the USPSTF, research is needed to clarify which indications primary care physicians currently use screening pelvic examination for in asymptomatic patients and which components of the pelvic examination are performed most frequently.

Up Next

The USPSTF is accepting public comments on this draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) until July 25.

After completing its review of the USPSTF's draft recommendation, the AAFP will release its own recommendation once the task force publishes its final recommendation statement.

Related AAFP News Coverage
Chlamydia Screens Dropped After Cervical Cancer Screening Change
Unlink Chlamydia Screening from Pelvic Exams, Cervical Cancer Tests, Study Suggests

(8/10/2015)

Choosing Wisely
AAFP Releases Third List of Tests, Procedures Patients, Physicians Should Question

(9/24/2013)


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