Key Points for Practice
• Screening pelvic examination should not be performed in asymptomatic, nonpregnant women.
• Possible harms include fear, anxiety, deterring some women from getting medical care, and false-positive results leading to unnecessary laparoscopies or laparotomies.
• Pelvic examination should not be performed for sexually transmitted infection screening; urine or vaginal swab testing is sufficient.
• Screening pelvic examinations are not needed before prescribing oral contraceptives.
From the AFP Editors
Pelvic examinations, consisting of speculum and bimanual examination for the purpose of this guideline, are often performed in women without symptoms to screen for pathology, including cancer, infection, and pelvic inflammatory disease (PID). However, their accuracy for diagnosing PID, gynecologic cancer (not including cervical or ovarian cancer), and benign conditions has not been addressed in studies, and their accuracy for diagnosing ovarian cancer and bacterial vaginosis is low. Additionally, pelvic examination is associated with many false-positive findings and harms from examination (e.g., unneeded laparoscopies or laparotomies, fear, anxiety).
Routinely performing pelvic examinations increases health care costs, with total yearly cost of preventive examinations, and the related laboratory tests and radiology, in the United States estimated at more than $2.5 billion. This guideline from the American College of Physicians (ACP) provides evidence on the use of pelvic examination to screen for pathology in average-risk, non-pregnant women. This guideline concentrates on screening in women without symptoms; a pelvic examination with bimanual examination may be used in some non-screening circumstances. Additionally, the group due for cervical cancer screening is not addressed in this guideline, but screening should be done by visual inspection of the cervix and cervical swabs, rather than performing a full pelvic examination.
Based on moderate-quality evidence, the ACP makes a strong recommendation that screening pelvic examination should not be performed in asymptomatic, non-pregnant women, with evidence indicating that harms outweigh the benefits of such screening in this population. Low-quality evidence has indicated that pelvic examination screening can lead to harms, possibly preventing some women from getting medical care. False-positive results from pelvic examination can lead to women having unneeded laparoscopies or laparotomies.
Nucleic acid amplification testing on vaginal swabs or urine has been shown to have high specificity and sensitivity for screening for chlamydia and gonorrhea. Pelvic examination should not be performed for sexually transmitted infection screening; urine or vaginal swab testing is sufficient. Many physicians continue to perform pelvic examination as part of the well-woman appointment; because it is considered to be of low value, it should not be performed in this setting. However, if a woman has symptoms of vaginal discharge, uncharacteristic bleeding, pain, urinary problems, or sexual dysfunction, pelvic examination may be necessary.
Physicians often insist that pelvic examination be performed before providing women with oral contraceptives; this practice does not have evidence to support it, and it is considered to be of low value.
Guideline source: American College of Physicians
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? Yes
Published source: Annals of Internal Medicine, July 1, 2014;161(1):67–72
Available at: http://annals.org/article.aspx?articleid=1884537