Editor’s Note: CNN Senior Medical Correspondent Elizabeth Cohen is the author of “The Empowered Patient.” The opinions expressed in this article are solely hers.
The American College of Physicians recommend against pelvic exams
The data backing the report was sketchy at best
Asked about exams causing urinary tract infections, the data didn't hold up
Pelvic exams have caught problems regularly
Ladies: I know you’ve heard the news that some doctors think you should just say no to your annual pelvic exam. “Doctors are examining your genitals for no reason” and “Skip the stirrups” were just a few of the headlines that followed last week’s report from the American College of Physicians.
But before you hop out of those stirrups, listen to what happened to this woman.
She went in for her yearly checkup, and the gynecologist did a regular pelvic exam – one hand in her vagina, one hand on top of her belly – and it was unusually painful. The doctor felt some inflammation and sent the patient for an ultrasound. More testing found pre-cancerous polyps in her colon, which she promptly had removed.
The patient was in her late 40s and wouldn’t have started regular colonoscopies until she was 50, so her pelvic exam caught the pre-cancerous condition early.
“I feel like my astute gynecologist saved my life,” the patient told me.
And this patient knows a few things about medicine: she’s Dr. Julie Gerberding, the former director of the Centers for Disease Control and Prevention.
So if pelvic exams can find bad things, why did the American College of Physicians recommend doctors skip them?
This group of internal medicine doctors – they’re not gynecologists – said that while there may be some success stories, those are merely anecdotes. The group said there are no actual studies showing pelvic exams help women, and it believes the exams could actually hurt them.
As someone with a master’s degree in public health, this made sense to me. But since my own annual exam is coming up, I decided to take a closer look. My conclusion: the American College of Physicians has made some judgments based on some very thin research.
So I am going to continue getting my exams. Here’s why:
During a pelvic exam the doctor inserts a speculum to open the vagina and look inside for things that shouldn’t be there, such as growths on the cervix. If you’re due for a Pap smear, the doctor will do one at this point in the exam.
Since the doctor can’t see the uterus, fallopian tubes and ovaries, he or she then removes the speculum and inserts two gloved fingers into the vagina and places the other hand on the lower abdomen to feel for abnormalities, such as inflammation, tumors or cysts.
Doctors have been doing this exam on women with no gynecological symptoms for as long as anyone can remember. There are plenty of studies showing the Pap smear saves lives, but does a visual and manual inspection do any good?
The American College of Physicians looked and didn’t find a single study that assessed whether routine pelvic exams save lives or make women healthier.
“I don’t want to do an exam that doesn’t have any documented benefit,” said Dr. Hanna Bloomfield, who, with funding from the Veterans Health Administration, reviewed the medical literature for the American College of Physicians.
I get it, but just because no one’s ever sat down and studied these exams doesn’t mean they’re useless – it just means no one’s studied them. So I called up a handful of gynecologists to ask if they’d ever made any great saves like Gerberding’s gynecologist.
While the catches might not be as dramatic, they’ve all caught bad stuff women wouldn’t have known about otherwise: warts on a woman’s cervix; HPV lesions that could have spread to a sexual partner; benign ovarian cysts that weren’t painful but could twist and rupture; and, on occasion, they found ovarian cancer.
That left me thinking I do want this exam, unless it causes me too much harm.
The American College of Physicians says “physical harms may include urinary tract infections.”
Yikes, I don’t want a urinary tract infection. But what’s the evidence that this actually happens?
Strangely, the organization’s guidelines didn’t give any, so I called Dr. Amir Qaseem, the lead author. He told me he got his information from the evidence report written by Bloomfield, but when I looked at that report, there was nothing.
So I gave Bloomfield a call.
“The data about urinary tract infections is bad data, so I didn’t include it in the final version of my report,” she said. “I don’t know why they put that in the guidelines.”
The past president of the American College of Physicians, Dr. Molly Cooke, says, both as a doctor and a patient, urinary tract infection doesn’t “figure into my benefit/harms calculus.”
Okay, I thought to myself: If the former president of the American College of Physicians isn’t worried, I won’t be either. So what should I worry about?
Unnecessary surgery, according to the college.
Sometimes your doctor will do a pelvic exam and see or feel something that they think is worrisome but is actually a big nothing, and you have surgery you didn’t need.
Tell us your story!
That sounds legitimate. But again, where’s the evidence?
The American College of Physicians cites one study.
That study, done in Greece, looked at 174 healthy women whose doctors found something worrisome on their pelvic exams. These women had more testing, and doctors decided to do laparoscopic surgery on 31 of them. Ovarian cancer was found in two of these women, so the American College of Physicians concluded that the other 29 had “unnecessary” surgery.
There are two problems with this conclusion. One, while these women didn’t have ovarian cancer, during the surgery doctors did find other things, such as benign ovarian cysts, that were removed. Maybe this was unnecessary. Or maybe it helped.
Bloomfield, the associate chief of staff for research at the Veterans Administration Healthcare System in Minneapolis, agreed that some of these surgeries she deemed “unnecessary” might actually have been helpful. It’s impossible to know because the Greek paper contains very few details.
The second problem with labeling these surgeries “unnecessary” is that the Greek women got their care from 1991 to 1993. Doctors are now much more adept at weeding out people who don’t need surgery because of better imaging technology.
“To extrapolate anything from a study done in Greece in 1992 to the U.S. in 2014 is unconscionable,” says Dr. Barbara Levy, vice president of health policy at the American Congress of Obstetricians and Gynecologists. The professional organization is not going to change its recommendations in light of this report, saying they believe pelvic exams can still be valuable.
So we have different doctors with different opinions. You and I get to be empowered patients and decide who we agree with.
For me, I don’t want to miss something that could be serious. I’ll take the small chance that an exam will lead me to an unnecessary surgery because before I would have that surgery I would ask good questions and get a second or third opinion if necessary to make sure I really needed it.
So ladies: if you choose to have a routine pelvic exam, do it with your vagina and your eyes wide open. Know that science isn’t perfect. But also know that you, and not a group of doctors looking at that imperfect science, will make that decision.