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 The conclusion issued by the U.S. Preventive Services Task Force (USPSTF)
today on pelvic exams comes amid growing debate in the medical
community over whether women really need a full pelvic workup every
year.
The new guidelines from the government-backed, independent panel of
primary care and preventive health experts don’t apply to pregnant
women, Pap tests for cervical cancer or checks for certain sexually
transmitted infections.
“The USPSTF strongly recommends that women be screened for cervical
cancer, so we understand that women will receive a pelvic exam in
that circumstance,” said task force member Dr. Maureen Phipps, a
women’s health researcher at Brown University in Providence, Rhode
Island.
“This new recommendation statement is about whether the pelvic exam
by itself is a useful tool to screen for a variety of other
gynecologic conditions,” Phipps said by email.
This is the first time the Task Force has weighed in on pelvic
exams, which typically involve the insertion of a speculum to widen
the vagina and visually examine the cervix as well as a manual
internal exam of the reproductive organs and rectum.
Among other things, doctors usually look for yeast infections,
genital warts, herpes, pelvic inflammatory disease, fibroids and
cysts. They may also check for cancers of the cervix, ovaries or
uterus.
Only eight studies since the 1940s have examined the accuracy and
harms of pelvic exams, with mixed results, the Task Force writes in
JAMA.
Taken together, the available studies don’t conclusively show the
accuracy or benefit of the exams for early detection and treatment
of many gynecologic problems. It’s also not clear how often women
might be harmed by inaccurate “false positive” results that lead to
extra tests and unnecessary treatment.
With ovarian cancer, for example, a few studies found false positive
results in 1.2 percent to 8.6 percent of cases. Between 5 percent
and 36 percent of women with abnormal results suggesting cancer got
surgery. Some studies also found “false negative” results that miss
malignancies.
Given the scant evidence, the American College of Physicians advises
against pelvic exams as part of annual physicals. The American
Congress of Obstetricians and Gynecologists, however, recommends
pelvic exams as part of annual checkups until women’s age or other
health issues make it unlikely they would choose to treat any
conditions detected.
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Currently, the USPSTF recommends a Pap test every three years for
women aged 21 to 29, and every five years for ages 30 to 65. The new
pelvic exam guidelines don’t change this advice.
Pap tests can be done without a full pelvic workup, and pelvic exams
can occur without a Pap test, Dr. Jeffrey Peipert, author of an
accompanying editorial, said by email.
“I do not think all women need an annual pelvic exam,” added Peipert,
an obstetrics and gynecology researcher at Indiana University School
of Medicine in Indianapolis.
With conflicting guidelines about pelvic exams, doctors should tell
patients there’s uncertainty about the value of these screenings and
discuss whether they’re needed on case by case basis, Dr. George
Sawaya of the University of California, San Francisco, writes in an
accompanying editorial in JAMA Internal Medicine.
Women might, for example, need exams when they have unusual pelvic
pain, vaginal bleeding or other concerning symptoms, Sawaya argues.
But some women without symptoms might not want the invasive exams.
“Prevention is designed to make well people in the present ‘weller’
in the future, and that is difficult,” Sawaya said by email. “This
is why we need to have a high standard of evidence for prevention -
we don’t want to make well people sick in our pursuit of making them
healthier in the future.”
SOURCE: http://bit.ly/2eRKuCu JAMA and http://bit.ly/2naD6FZ JAMA
Internal Medicine online March 7, 2017.
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