health

The optional extra after your pap smear, that doctors are divided on.

Is this trip to the gyno actually a waste of time?

You know that moment when you’re at the gynaecologist, or the GP, and your pap smear is over, and your pelvic exam begins?

The doctor generally feels around your belly and pelvic area while also having their fingers inside you. It’s generally uncomfortable (as is the entire pap smear process), and occasionally even unpleasant. But like so many other things in life, it’s something women put up with because we know that it’s good for our health.

Except… it might not be so good for our health after all. In fact, pelvic exams have been making headlines for some time now, with various studies suggesting that the entire exam process is actually relatively useless.

And last week, the American College of Physicians – America’s largest medical-specialty organisation – released new guidelines that give a “strong recommendation” against performing pelvic examinations on women who are not pregnant and have no symptoms.

The ACP reviewed published literature from 1946 through to 2014 to determine just how useful the pelvic exam is when screening for pathology. They examined accuracy of the screening pelvic examination in detecting cancer, pelvic inflammatory disease and other gynecologic conditions. They also examined issues relating to overdiagnosis and overtreatment, with false positives being very common.

The result? The “diagnostic accuracy of the pelvic examination” was very low – in other words, it did little to detect any problems. 96.7% to 100% of abnormal pelvic examinations did not identify ovarian cancer, and there was no reduction in cancer mortality rates that could be associated with the pelvic examination.

However, significant harms were found through the study – including “fear, anxiety, embarrassment, pain, discomfort and urinary tract infections and symptoms, such as dysuria and frequent urination.” 10% to 80% of women who experienced a pelvic exam reported feeling fear, embarrassment, or anxiety, and some even experienced pain – as a result, they were less likely to return for another exam.

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Anyone who’s ever had a pelvic exam is probably nodding their head at this point. In the realm of pleasant-to-unpleasant experiences, pelvic exams (and the generally accompanying pap smear) rate somewhere between dodgy Brazilians and stepping on itty-bitty pieces of Lego.

So right now, you might be pretty excited at the news that the ACP deemed pelvic exams to be useless and unnecessary, as the “harms outweigh any demonstrated benefits associated with the screening pelvic examination.”

However – it’s not time to go cancelling your next gynaecological appointment just yet. In fact it is never time to cancel that appointment – it’s important y’all.

There has been significant debate around the issue of pelvic examinations, and not all organisations or practitioners agree with the recommendations of the ACP. In fact, the American College of Gynecologists released a statement last week that they had reviewed the recommendations, but continue to stand by their own guidelines:

The College continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction. While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients. Pelvic examinations also allow gynecologists to explain a patient’s anatomy, reassure her of normalcy, and answer her specific questions, thus establishing open communication between patient and physician.

Confused now? Yes, me too. So I asked Dr Martin Ritossa, a Spokesperson from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, about the official Australian recommendations in regards to pelvic examinations.

Martin

Natalia: What do you say to the suggestions that pelvic exams are unnecessary?

Dr Ritossa: In Australia, we have one of the most successful screening programs for cervical cancer in the world. This involves an internal examination every 2 yrs. Although the frequency of these examination is currently being debated, it is very important that women and doctors adhere to the current recommendations until any new protocols are approved.  Pelvic examinations are an important part of the investigations for any women who present with gynaecological symptoms.

N: Do you think that women should continue to have pelvic exams, even if there are doubts about their usefulness?

Dr Ritossa: Women who do not have any gynaecological symptoms and who are not due for a pap smear do not need a pelvic examination. Otherwise, women and doctors should adhere to the current recommendations, which involves an internal examination every 2 yrs.

Although the frequency of these examination is currently being debated it is very important that women and doctors adhere to the current recommendations until any new protocols are approved.

N: What about women who feel particularly uncomfortable about the exam?

Dr Ritossa: Patients should ensure that they establish a partnership with a GP who they trust and respect, who they know will only do an intimate examination with consent when it is required.

Doctors should always fully inform patients of the need for any examination and have a chaperone available if required. It is important that patients feel empowered to ask any practitioner about the need or process of any examination.

So, in conclusion?

Don’t get your hopes up about skipping the pelvic exam altogether – the doubt is still there. And while no one has reached any hard and fast conclusions about the pelvic exam, it makes sense that it should continue to be part of the regular check-up process for women visiting their doctor for the process every two years.

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