On March 7, the U.S. Preventive Services Task Force (USPSTF) published its final recommendation statement(www.uspreventiveservicestaskforce.org) and 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)
After reviewing this final recommendation and scouring its evidence report, however, the AAFP has made its own recommendation against screening pelvic exams in asymptomatic women -- a "D" recommendation.
In an April 11 memo to AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., representatives of the AAFP Commission on Health of the Public and Science (HOPS) Subcommittee on Clinical Preventive Services noted that malignancy and pelvic inflammatory disease are the leading gynecologic causes of morbidity and mortality in women.
"Screening for other conditions that have limited effect on morbidity or mortality (is) unlikely to provide substantial benefit," said the memo. "There is evidence of harms for performing screening pelvic exams in asymptomatic women due to the increased risk of invasive testing and unnecessary treatment. Given the low likelihood of benefit and the increased risk of harm, the AAFP recommends against screening pelvic exams."
- In a departure from a recent U.S. Preventive Services Task Force recommendation, the AAFP recommends against conducting screening pelvic exams in asymptomatic women.
- In its review of evidence, the AAFP focused on gynecologic conditions that cause the majority of morbidity and mortality in women: malignancy and pelvic inflammatory disease.
- In 2014, the AAFP endorsed the American College of Physicians guideline recommending against performing screening pelvic exams.
It should be noted that this was the first time the USPSTF had reviewed evidence on screening for a wide range of gynecologic conditions using pelvic examination. The task force had 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), so screening for these conditions was not included in the USPSTF's current evidence review.
AAFP Recommendation Explained
Jennifer Frost, M.D., medical director for the AAFP HOPS Division, told AAFP News the USPSTF's recommendation differs from most other of its recommendations in that it is not about screening for or preventing a specific disease state. Instead, the task force considered the potential benefits of the pelvic exam to reduce morbidity and mortality.
What the USPSTF determined, said Frost, was there were many potential conditions that could be found through screening pelvic exam, but there weren't studies for all of them, which led to the "I" recommendation.
"While we agree there is insufficient evidence for all potential gynecologic conditions, the AAFP focused on those that cause the majority of morbidity and mortality in women: malignancy and pelvic inflammatory disease," she explained.
Frost said ovarian cancer is a malignancy frequently screened for with pelvic exam and there is adequate evidence that pelvic exam isn't a good screening test for this condition. The harms of pelvic exam include unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain and discomfort, she added.
"Although there are not studies to determine the benefits and harms of screening pelvic exam for fibroids, we determined that the potential for improving morbidity and mortality in an asymptomatic woman with fibroids and without symptoms was minimal," Frost said.
Endorsement of ACP Guideline
On a similar note, in 2014, the AAFP endorsed the American College of Physicians (ACP) guideline(annals.org) recommending against performing screening pelvic exams.
The subcommittee members said in their memo that accepting the USPSTF's "I" recommendation wouldn't have been consistent with this stance and would actually be contradictory. However, the AAFP's "D" recommendation is consistent with the ACP guideline.
Like the AAFP's recommendation, the ACP's guidance was based on evidence that pelvic exam isn't an effective screening test for the main conditions that cause morbidity and mortality in women: malignancy, STDs and pelvic inflammatory disease.
"The ACP recommendation did not consider the potential benefit of screening for fibroids or pelvic floor dysfunction," the memo said. "While the detection of these conditions in asymptomatic women may or may not affect outcomes, the potential for causing harm through evaluation and treatment is real."
Frost said it's important to remember that the AAFP's recommendation applies to asymptomatic, nonpregnant women.
"Family physicians have a lot to address with their patients, with limited time," she said. "We encourage family doctors to prioritize screening tests that have proven benefit for their patients."
Related AAFP News Coverage
USPSTF Final Recommendation
Evidence Lacking on Routine Gynecologic Screening Pelvic Exams