Dr. Jones: There is an annual rite of American womanhood, the yearly Pap and pelvic exam. Many of us did it, but most of us didn't want to. Maybe we believed, as we were told, that it was a way to keep our lady parts safe and detect cancers and diseases before there was real harm. What is the evidence that this annual ritual is necessary and saves lives, and what is the raging debate?
This is Dr. Kirtly Parker Jones from the Department of Obstetrics and Gynecology here at the University of Utah Healthcare, and today we're going to jump right into the fray and debate the pros and cons of the annual pelvic exam on The Scope.
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Origins of the Annual Pelvic Exam
Dr. Jones: Women live a lot longer, on average, than they did 150 years ago. We in medicine like to believe that it's due to better healthcare, better treatments for disease, and better screening tests for diseases that can be treated early. In reality, it's probably vaccinations and better treatments for early childhood diseases, and much better access to care in pregnancy so fewer women die in childbirth.
In the late 1940s, Dr. Papanikolaou-great name-invented a way of looking at cells from the cervix to detect cervical cancers and pre-cancers, and the Pap smear was introduced into women's health care. It's an excellent screening test for cervical cancer, and thanks to the use of the Pap smear deaths from cervical cancer decreased dramatically. Without much data, it was suggested that women get a Pap smear every year, and to do that women had to have a pelvic exam, and the annual pelvic exam was born.
The Debate Surrounding Annual Pelvic Exams
However, we now know much more about what causes cervical cancer, and how to do Pap smears, and how often they should be done to save lives, and it isn't every year. Today on the Scope we're talking about the debate raging in the national news, at least it's raging in my news, about women without any gynecologic problems whether they need a pelvic exam every year.
What's the fuss? On July 1, 2014 the American College of Physicians published a report for the clinical practice guidelines for the screening pelvic examination for asymptomatic, average risk adult women. Okay, there's a lot in that line. It's how often should we do a screening pelvic exam, meaning women aren't symptomatic, and they're average risk, meaning they don't have a history of problems that need to be followed up.
Essentially, the scientific evidence points to data that says screening pelvic exams for the average woman without symptoms:
- Bleeding
- Pain
- Pressure
- Urine problems
Those kinds of symptoms-doesn't save lives in an analysis of large populations.
Now, large population studies are what really drive policy and what your insurance is going to pay for. A large percent of women, on average 35% with a range of 10% to 80%, depending on the study and the women, say they were uncomfortable and embarrassing. That's what we all remember. We went and we did this annual exam, but it wasn't very fun and it was kind of embarrassing.
"Whoa," said the American College of Obstetricians and Gynecologists. "We gynecologists know we have saved the lives of women by picking up problems they didn't know about, so we still recommend the annual pelvic." One group, the American College of Physicians, is talking about large groups of women and national policy. The other group, the OB/GYNs, is talking about individual women.
Who Needs a Pelvic Exam?
What are the facts? First, Pap smears need to begin at age 21 if women are sexually active. Or, if they've never been sexually active-do I need to define that for the radio? I don't think so-they can begin after age 21 when they become sexually active. After the first Pap they need a Pap every three years. After age 30, they can do a Pap every 5 years if they include a screening test for the virus that causes cervical cancer in most women. All this is dependent on the Pap smears being normal. Women with abnormal Pap need more frequent follow up.
What About Cancer Screening?
What about other female cancers-ovarian, uterine, and vulvar cancers? The annual pelvic exam isn't very good as a screening test for these cancers. By the time the cancers can be picked up on a pelvic exam they've already grown quite a bit. Remember, we're talking about the annual exam for women who have no symptoms.
What About STIs?
Well, what about sexually transmitted infections? Women who have symptoms of pain or a vaginal discharge need an exam. Women without symptoms who are at risk can be tested by a urine test for gonorrhea and chlamydia and a blood test for some of the others.
Well then, what about non-cancerous growths of the uterus and ovaries? Again, if it isn't a cancer we usually wait until there are symptoms of one kind or another before we actually need a pelvic.
When Do I Need a Pelvic Exam?
When do you need a pelvic exam? You need it for that Pap every three to five years. You need it if you have symptoms of
- Abnormal bleeding,
- Pain,
- Vaginal discharge,
- Vulvar problems,
- Pelvic discomfort,
- And infertility.
You need it if you have problems down there. If you have a family history with two members in your immediate family with ovarian cancer you need a different kind of screening than just a pelvic exam.
All women who are not planning pregnancy right now and are sexually active with men need contraception. You don't need a pelvic exam for most kinds of contraception, but you do need a pelvic exam for the most effective form of contraception, the I.U.D.
What About Breast Exams?
Well, what about those lady parts above the waist? What about the breast exam? There's no evidence that the breast exam by a clinician saves lives for women under 40 and not much evidence after 40. Again, this is for women with symptoms.
Know What Your Options Are
Importantly, the decision about whether an asymptomatic, average risk woman needs a pelvic or breast exam should be shared. That decision should be shared with the patient and the clinician. The patient's worried and wants to have a pelvic exam and understands the limitation, it should be done. Often, women who are worried are worried because they have some non-specific symptoms or have a personal or family history of something that makes them worried. It's a discussion between the clinician and the patient.
Talk to Your Provider
What is the annual exam that is paid for by your insurance company supposed to do, and who should do it? The annual exam should be a health discussion about things you should do for your health diet and exercise; and things you shouldn't do to your body, smoking and excessive alcohol. You should get your blood pressure checked, your vaccinations where appropriate, and some screening labs for sexually transmitted infections when appropriate, as well as some other screening labs. You could do all this with an M.A. or a nurse practitioner, and you can leave your clothes on.
If, however, the discussion reveals symptoms or risks, it may be time to "take everything off below the waist, and here's a gown and a drape for you, and the doctor will be in in a minute or so." If the recommendations are in flux and it depends on whom you talk to, have the discussion with your clinician if you have no symptoms, and no increased risk, and it isn't time for your Pap yet.
That's the scope of the issues of the annual pelvic exam on The Scope, and this is Dr. Kirtly Jones. Thanks for joining us.
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