Millions of healthy women undergo routine pelvic exams every year, but on Tuesday a panel of physicians and other medical experts cast doubt on this longstanding pillar of women’s preventive health care.
The US Preventive Services Task Force, which advises the federal government on preventive care, concluded that there is not enough evidence to recommend the procedure for healthy women. Studies have not shown that pelvic exams decrease a woman’s chance of developing illnesses such as ovarian cancer or of dying prematurely, the task force said.
Doctors who perform routine pelvic exams have vigorously defended their worth against previous criticism, but on Tuesday their organization, the American College of Obstetricians and Gynecologists, backed away from that firm stance, acknowledging there is little to no evidence that the exam benefits asymptomatic women.
The task force finding is the latest reminder that many seemingly sensible procedures have little basis in science and fewer clear benefits than once thought. In recent years, procedures such as screening mammograms and PSA tests for prostate cancer, and even annual physicals, have turned out to be of questionable benefit.
Its conclusion applies only to women who are not pregnant and who do not have pelvic symptoms, such as pain or unusual bleeding. It gave the pelvic exam a grade of “I,” for “indeterminate,” meaning “we don’t have enough evidence to determine the benefits and harms,” said task force member Dr. Maureen Phipps, professor of obstetrics and gynecology at the Warren Alpert Medical School of Brown University and chief of OB-GYN at Women & Infants Hospital of Rhode Island.
The public can comment on the draft recommendation, which was accompanied by a 71-page review of the scientific evidence, through July 25. After considering the feedback, the task force will issue a final recommendation, which the federal government and some private insurers can use to decide what procedures to cover.
The recommendation is unrelated to screening for cervical cancer, which the task force highly recommends. But that can be done without a pelvic exam, an internal and external inspection by sight and touch.
In 2014, the American College of Physicians, which represents internists, reached a similar conclusion, finding that routine pelvic exams have not been shown to benefit asymptomatic women. The procedure rarely detects hidden disease and does not reduce mortality, the group concluded from decades of studies.
Obstetricians and gynecologists disputed the internists’ position; ACOG currently endorses annual pelvic exams for women 21 and older. But it is reviewing the task force’s draft recommendation, said ACOG president Dr. Thomas Gellhaus. His group’s current recommendation “is based on expert opinion” rather than rigorous scientific evidence, he said, and the “limitations” of pelvic exams “should be recognized.”
ACOG also acknowledges that “data do not support the necessity” of a pelvic exam before a woman starts oral contraceptives or to screen for sexually transmitted diseases such as chlamydia or gonorrhea. Those can be detected by urine samples or vaginal swabs.
There are two main reasons pelvic exams are of questionable value: their minimal benefits and their potential to cause harm.
Pelvic exams can find endometriosis, ovarian cysts, uterine fibroids, warts, herpes, pelvic inflammatory disease, and cervical polyps. But research has not shown that detecting and treating these before they produce symptoms is better than waiting for early symptoms to appear, said Dr. Amir Qaseem, vice president for clinical policy at the American College of Physicians. “You want to find things before they cause symptoms only if you have treatments that will keep full-blown symptoms from appearing,” he said. “We don’t have those for the conditions pelvic exams find.”
The exams can also cause harm (in addition to discomfort, for some women), said Phipps. Their rate of “false positives” — finding an apparent problem that isn’t there — ranges up to 46 percent. For instance, when a pelvic exam “detects” ovarian cancer, the chance that the woman actually has that often-fatal disease is 0 percent to 3.6 percent. But a woman given that frightening news, or the less dire news that she has a less serious condition such as ovarian cysts or fibroids, will typically undergo additional, sometimes risky, tests, including biopsies and even surgery for something that might never have affected her.
Pelvic exams can also give false reassurance. When an exam finds no sign of ovarian cancer, for instance, there is a chance the woman actually has it, according to studies reviewed by the task force. Such “false negatives” can cause a woman to ignore early symptoms of a potentially deadly disease, Phipps said.
An estimated 76 percent of preventive care visits to OB-GYNs include a pelvic exam, and US physicians performed 62.8 million of them in 2010, the last year for which the task force had data. Insurers typically reimburse doctors about $35 for them.
ACOG said its current position is not dictated by financial considerations. But if women opt out of pelvic exams, many might visit a gynecologist less often. And if gynecologists do not bill for a pelvic exam and the follow-up it often triggers, their incomes would decline.
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Cervical cancer is RARE. I’ve had family members die of brain tumors. My grandmother passed of brain tumor, two of my uncles and one aunt same thing. I should probably go in once a year and have an evaluation of my brain but no lets worry about the vagina. Always. No I have been in a platonic relationship for many years. Had last baby no pelvic exams or pap smear. Its a waste of time and I actually believe during a pregnancy. The pap test killed my unborn child. Everything was perfect. Went in got scraped and three days later my baby was found dead and had been for a couple days. Coincidence? I don’t think so! I will only see a gyno in an emergency like they did in the old days. If nothing is wrong leave it alone.
I am so sorry to hear about what happened to your unborn child. I agree with your last statement ” If nothing is wrong, leave it alone”. The current clinical guidelines from American College of Physicians is if you are asymptomatic and non-pregnant, an annual pelvic exam is NOT recommended. The American College of Ob-Gyn disagreed with the recommendation in 2014 but ACOG changed its mind in 2017 due to available clinical data and recommended that patients should discuss this with their Ob-Gyn and make a shared decision. US Preventive Services Task Force basically says annual pelvic exam offers no benefits to asymptomatic non-pregnant women. So my own interpretation of these recommendations is consistent with yours “if nothing is wrong, leave it alone” but this only applies to women who are asymptomatic and non-pregnant. And it should be your decision, not shared nor the Ob-Gyn’s. It’s your body, you have the autonomy to make that final decision. If your Ob-Gyn coerces you to have one and does not respect your decision, you should leave that doctor and find a new one. With respect to pap smear, there are about 11,000 new cases of cervical cancer annually. 55% of these new cases happen to women who have never been screened. The current recommendation from all medical and cancer societies is a pap smear every 3-5 years depending on your risk factor. Pap smear is a very invasive procedure and it has very high false positive result. There are tons of clinical data if you google it. Again, it’s your decision whether you should have one periodically.
The guiding principle to see a doctor is when you have symptoms or you know you are predisposed to certain diseases due to genetic or family history. A doctor should not perform any unnecessary tests unless there is a medical reason for it. In my opinion, the annual pelvic exam is a joke and it goes to show you why US spends so much on healthcare and yet our life expectancy is one of the lowest among all developed countries. Imaging what the annual cost of $3.5 billion on pelvic exam can do to improve our healthcare if the money is spent on other high priority diseases. If OB/GYN’s argument for annual pelvic exam is for wellness even for asymptomatic non-pregnant women, then we might as well conduct other tests to ensure our brain, heart, lung, kidney, liver, pancreas, and every organ to make sure these organs are healthy annually. If OB/GYN do not practice evidence based medicine, they will destroy their own career in the near future.
My wife had more pelvic exams by the age of forty than she had years of life, it wasn’t only gynecologists but regular medical doctors “just to be on the safe side was the excuse” I know abuse wend I see it if only I could convince my overly trustful wife.
I face the same situation. I have had trouble convincing my wife not to have the pelvic exam and pap smear because there is no scientific justification other than the doctor getting paid. My wife has had 30 years of negative pap, how many more she has to do to proof that she doesn’t have cervical cancer. If the doctor follows guidelines, my wife will only need to do a pap smear every 5 years. I will try to convince her again not to have the pelvic exam and pap smear. This really has become a habit or ritual as some medical experts were saying. The dark side of American medicine.
The way I got my wife to finally agree with the new recommendations against a routine pelvic exam is to show her all the facts on the internet. The American College of Physicians and the American Academy of Family Physicians both recommend against doing pelvic exams on healthy women, who are pregnant and don’t have symptoms. Let her decide for herself. My wife has always hated her yearly visit with her gynecologist. Now that she knows the truth, she will never go again without medical cause. Now that she has had a total hysterectomy, a routine pelvic exam will never be necessary without symptoms. Good luck
This is advice is long overdue. In fact, Stanley is correct, for years I could only get birth control after having a pelvic exam. It was stupid. The irony was that they didn’t even measure my blood pressure or do blood work to make sure that the birth control wasn’t affecting my heart – which is one of the biggest risks of taking birth control!
The field of women’s health (hellth?) needs to be improved. The greatest risk to women? Heart disease. Many women think of their gynecologist as their primary physician and yet, most gynecologists overly focus on the lady parts without truly providing holistic care. So, the heart gets ignored.
The risks of pelvic exams and mammograms (the other lady part!) are always minimized, so I’m glad to see an evidence-based approach question their effectiveness. I’m sure that even if many women are told the pros/cons of pelvic exams and mammograms, they will still get them – but they’re not told, and this is where I have the greatest heartburn with the field of gynecology as it is today. Trust me, if you tell a gynecologist that you’re not going for a mammogram, you will get a nasty letter telling you that you are ‘non-compliant’ and that you need to be an ‘active participant’ in your health or find care elsewhere. I did find care elsewhere, but the letter really threw me for a loop because I never had one like it before. I know that I have autonomy over my body and don’t have to get any tests I don’t want to. Many women are shamed into returning and getting tests/exams that they don’t want. It’s horrible.
I totally agree! As someone who is overweight, I can always tell that the manual exam was of no use.- I could see on the facial expression that they were basically just jamming their fingers in and pressing on my abdomen haphazardly for a few seconds as if to say “I can’t feel anything useful but I’ll just keep pressing around a bit for a period of time so that we can all say a pelvic exam was conducted”. Besides being useless, this practice lengthens the amount of time the patient spends in a supine , exposed and mentally degrading position.
I totally agree as well. Pls google “PLCO cancer trial screening study results” and read all the publications from this 20 years study on 160,000 participants on the lack of benefits of pelvic exam. It’s very troubling and worrisome when doctors don’t follow scientific evidence and guidelines not to perform pelvic exam on asymptomatic and non-pregnant women. If your doctor doesn’t take “no” for an answer or send you a “non compliant” letter, it’s time to say goodbye to that doctor. You have the autonomy over your body, you are the one who makes the final decision, not your doctor.
Comment to MegNP:
Her comment to Stanley’s comment, was that his statement was drastic over-generalization. It makes OB-GYNs sound monstrous and malevolent. Some are very monstrous and malevolent. This may come to a shock to you but most women consider a pelvic exam one of the worst things a healthy women can have/with no gain. A woman can feel her abdomen and pelvic area to see if there are lumps or pain.
There aren’t any lies to my statement/Stanley. My wife has gone to this gynecologist during and after her complete hysterectomy, approximately (6) years ago. The year before last year, she was badgered into getting a pelvic exam as well. They said that it had been awhile since her last pelvic and that she should get one. Yes, they even told her again that her insurance would pay for it.
This last year they wouldn’t even do the blood work, unless she had booked a return office exam for a pelvic and to get her thyroid Rx.
There is no exaggeration to this office wanting to do pelvic exams, without medical reasons or symptoms. If a Doctor was to talk with each patient and tell them that the pelvic exam was necessary and state what symptoms would need a pelvic exam, that would be different. The decision to have a pelvic exam should always be the patients, unless there are symptoms. Her gynecologist didn’t care and never asked her, even once, if she had any problems or symptoms. My wife even told her that she had a pelvic exam last year. It didn’t matter. They still demanded one if she wanted her thyroid prescription filled.
There may be exceptions with some gynecologists. Still a family doctor is governed by real medical reasons/symptoms before doing a pelvic exam.
Like I said before, never go to a gynecologist unless you are pregnant and/or have pelvic symptoms.
If any of you have questions, go to the internet. You will find a huge amount of support in stopping gynecologists, giving pelvic exams, without medical reasons/symptoms and getting twice the money by doing so.
Hi Stanley, I just want to clarify one of your sentences – “The decision to have a pelvic exam should always be the patient’s, unless there are symptoms”. It should be “The decision ……… EVEN when there are symptoms”. It’s your body, it’s your decision, period. You can also refuse treatment if you wanted to. When a doctor behaves badly or extort you into a pelvic exam, walk away and find another doctor, don’t even argue with him/her. Walk away is a very powerful message to the doctor. In addition, you can write an online review by telling readers what happened, just state the facts, do not use subjective wordings. I think a lots of women will thank you for the review. Doctors may change their behavior when they see their reviews and realize they are assholes if they really care about their patients and practices.
I too believe that healthy women who aren’t pregnant and don’t have any pelvic symptoms (abdominal pain, bleeding etc) don’t need a pelvic exam. Note: Women who haven’t had a hysterectomy still need a pap smear every (3) years or (5) if they get it with a combined HPV test.
If you need your birth control pills renewed or need other Rx, go to your family doctor, not a gynecologist. Without symptoms, your family doctor will not perform a pelvic exam. Gynecologists will probably require you to have one, no matter what. They want you to believe that you would be expected to have a pelvic exam if you go to their office.
Example: My wife went to her gynecologist this past year, to get her thyroid Rx refilled. They wouldn’t even take her blood test, unless she had an appointment already made for a physical/pelvic exam. Needlessly she left very upset and in tears. She made an appointment to her Family Doctor and got her blood work and Rx without a physical or pelvic exam.
Additional Info: Before going to her Family Doctor, she called her gynecologist office back and questioned them on why they insisted on doing a pelvic exam. Their defense for requiring her to have a physical and pelvic exam, was that my wife’s insurance would pay for it.
Have you ever wondered why your insurance premiums are always increasing? Gynecologists could care less about putting a woman through the most embarrassing thing a healthy woman could do without medical justification and symptoms. By doing a pelvic exam, they can charge over twice the amount of a normal office call.
Best Advice: If you aren’t pregnant or don’t have pelvic symptoms, never go to a gynecologist to get your meds filled or anything else. Make your appointment with your General Practitioner or Family Doctor. Their guidelines require a real medical reason(s) and symptoms, for doing a pelvic exams.
First of all, there have been new released recommendations on routine pelvic exams. The American College of Physicians (Family or General Practitioner guidelines) in July 2014 completed a 50 year study on pelvic exams and have made the following recommendations:
Healthy women who aren’t pregnant and don’t have any pelvic symptoms (abdominal pain, bleeding etc) don’t need a pelvic exam. Note: Women who haven’t had a hysterectomy still need to have a pap smear every (3) years or (5) if they get it with a combined HPV test.
Women are perfectly capable in detecting pelvic problems on their own, and then this would warrant a pelvic exam. Routinely women have been herded into the exam room and put in the stirrups without symptoms and medical cause. They state that it is an expectation, no kidding. An expectation that has been going on for decades. The real expectation is that the gynecologist and charge you more than double if they can badger you into letting them do one to you. Doctors would educate women more, if they weren’t afraid of decreasing their business and income. Plus, you have to know they enjoy getting a look as well.
If you need your birth control pills renewed or need other Rx, go to your family doctor. Without symptoms, they will not perform a pelvic exam. A gynecologist will probably require you to have one. They will be more than happy to put you in the stirrups, so they can more than double their fees.
Example: My wife went to her gynecologist this past year, to get her thyroid Rx refilled. They wouldn’t even take her blood, unless she had an appointment already made for a physical/pelvic exam. Needlessly she left and went to her Family Doctor and got her blood work and Rx without a physical or pelvic exam.
Note: Before going to her Family Doctor, she called her gynecologist back and questioned them on why they needed to do a pelvic exam. Their defense for requiring her to have a physical and pelvic exam, was that my wife’s insurance would pay for it. Have you ever wondered why your insurance premiums are always increasing. Gynecologists could care less about putting a woman through the most embarrassing thing a healthy woman could do without medical justification. By doing a pelvic exam, they can charge over twice the amount of an office call.
Best Advice: If you aren’t pregnant or don’t have pelvic symptoms, never go to a gynecologist to get your meds filled. Make your appointment with your General Practitioner or Family Doctor. Their guidelines require a real medical reason for pelvic exams, not just to do them routinely, without symptoms.
I feel that this comment is an drastic over-generalization. It makes OB-GYNs sound monstrous and malevolent. This is certainly not the case. I myself am a women’s health nurse practitioner and work in an OB-GYN office. I would NEVER force a patient to have a pelvic exam, especially to simply refill medication. The American College of Obstetricians and Gynecologists encourage providers to make the decision of whether or not to do a pelvic exam with the patient. Some women report symptoms in a routine review of symptoms that may indicate issues never realizing that these symptoms could indicate a bigger issue. This subtle nuance could be missed by a provider not thoroughly familiar with women’s health issues. There is value in pelvic exams. I’ve witnessed this value over the ten years that I have been practicing. Advising women to avoid their OB-GYNs based on your wife’s experience is unfair and reckless, in my opinion.
If the shoe fits, wear it. Ob/gyns are monsters. They have reaped the benefit of ignorant women for decades and will still do it. The American College of Obstetricians and Gynecologist still recommend an annual pelvic exam on all women not matter what. They all chose to look at women and get paid a lot for not medical reasons. More a ritual from the past than anything else. Plus, most will never let their females be involved in the decision process. Most will protect their jobs and income and pass the cost to their female patients as well as the patients embarrassment.