The pelvic exam, a common but often uncomfortable ritual for millions of American women, might be unnecessary for those who don't have symptoms of a gynecological problem.
Research led by the Minneapolis Veterans Medical Center found no evidence that the exam benefits women without symptoms, but plenty of indications that it causes discomfort and even pain and anxiety afterward.
"Without symptoms, we don't need to be mucking around in there," said Dr. Hanna Bloomfield, a physician and researcher for the Minneapolis VA's Center for Chronic Disease Outcomes Research.
The findings were published Monday in conjunction with new guidance from the American College of Physicians against the exam for asymptomatic women.
While it could change the regular medical care that women receive, the recommendation is also expected to generate controversy on the same magnitude as a 2009 change in the guidance on mammograms for women younger than 50.
Bloomfield stressed that the findings applied only to women lacking symptoms, and that pelvic exams remain important for women suffering abnormal vaginal bleeding, lower abdominal pain and other symptoms.
Pelvic exams are common parts of well-women visits that are often fully covered as preventive services by insurance plans. An estimated 62.8 million pelvic exams were conducted in the United States in 2010.
"It's been the standard of care for everyone," said Dr. Jon Nielsen of Oakdale Obstetrics and Gynecology, who argued that "it's still the best way to identify ovarian problems."
Well-women visits also typically include screenings for breast cancer and Pap smears for cervical cancer — though the latter is now recommended only every three years in women ages 21 to 65.
The pelvic exam typically involves a visual inspection of the external genitals, the use of a speculum to view the vagina and cervix, and then a "bimanual" exam in which a doctor uses one hand to feel inside a patient's vagina and another to press on her abdomen to feel for any abnormalities in the shapes of the ovaries or uterus.
Analyzing survey responses of more than 10,000 women who participated in earlier studies, VA researchers found that one-third expressed fear, embarrassment or anxiety related to the procedure. The research review also found reports of unnecessary surgeries and other procedures performed due to pelvic exams that found abnormalities that turned out to be benign.
"When you're screening … an asymptomatic person, you need some evidence that its going to benefit them," said Bloomfield, who led the study at the prompting of VA officials. "I think the burden is on someone who wants to do a procedure to show that it is useful."
Practice is already changing
The results appeared in the Annals of Internal Medicine along with an editorial saying the exam "has become more of a ritual than an evidence-based practice."
The guidance directly contradicts the American College of Obstetricians and Gynecologists, which supports the pelvic exam as part of an annual checkup for women 21 years and older.
A tiebreaker could come from the influential U.S. Preventive Health Services Task Force, which reportedly is launching its own review of the need for pelvic exams. The task force was among the groups that in 2012 recommended that Pap smears are needed only every three years, in part due to increased understanding of the origins of cervical cancer and its connection to the human papillomavirus (HPV). It also made the politically controversial 2009 recommendation for fewer mammograms — one that advocacy groups criticized and some women and doctors ignored.
Nielsen said the absence of evidence in favor of pelvic exams doesn't mean they aren't effective at identifying reproductive health problems when conducted by specialists such as OB-GYNs.
A move away from pelvic exams has been slowly underway since the Pap smear recommendation, said Dr. Krista Skorupa, director of HealthEast Women's Care and a Roseville physician.
Eliminating the test will eventually buy precious time to talk about cardiac risks and other health concerns for women, she said. For now, she added, it takes longer to explain why pelvic exams and Pap smears aren't needed than to actually do them.
Women have become so used to the exam that they now expect it. Some are happy to forgo it when they learn it isn't necessary and doesn't help doctors detect cancers of the reproductive organs. Others still want the exam out of caution.
"There's a lot of misconceptions on the patients' parts," Skorupa said, "of what we're actually doing when we're doing a pelvic exam."