Changing the Women’s “Annual Exam” (Again!): What to Expect This Year

By Anna E. Mazzucco, Ph.D.

 

July 7, 2014

 

                For many women, a yearly trip to the gynecologist is part of their routine, although they may not necessarily look forward to it.  Is this annual tradition getting overhauled?  What’s going on and what does it mean for you?

 

Recent Changes to the Annual Exam

Here’s what you need to know.  Experts agree that an annual Pap smear is not necessary for most women who don’t have any symptoms or concerns.  Since 2012, the American Congress of Obstetricians and Gynecologists and other medical societies have recommended Pap smears only every 3 years, starting at age 21, whether you’re sexually active or not.  Pap smears are important whether or not you ever had the HPV vaccine.  For women 30 and older, if you have both a Pap smear and an HPV test (not the same as the HPV vaccine) at the same time, you can wait 5 years between Pap smears, unless you’ve had an abnormal result in the past.1

Another familiar aspect of a woman’s annual exam may soon be changing, too.  Many women have pelvic exams done every year as well.  In this exam, also referred to as an “internal exam” or “bimanual exam,” a woman is lying down on the exam table with her feet in the stirrups, while the physician uses his or her hands to examine inside the vagina while pressing on the abdomen at the same time.  The Pap smear, which takes a sample of tissue, is often done at the same time.  In July 2014, one of the largest medical associations, the American College of Physicians (ACP), released a report stating that annual pelvic exams are unnecessary for non-pregnant women with no symptoms or concerns.2 Their report pointed to studies showing that the exams are not useful at diagnosing or preventing diseases, and have potential risks and high costs.

 

Pelvic Exams: Why Are They Done?

Traditionally, pelvic exams have been used to check for sexually transmitted diseases (STDs), cancer, and as a check prior to prescription of contraceptives.  However, the ACP report and other studies suggest that pelvic exams very rarely detect cancer,3 and there are more accurate ways to test for STDs with blood or urine tests.  Another study showed that using pelvic exams to screen for ovarian cancer led to unnecessary surgery in 1.5% of patients.4  And women don’t like these exams, with 60-80% reporting pain, discomfort, anxiety, or embarrassment.2  The ACP report also cites a study which estimated total costs to the health care system of $26.1 billion due to these ineffective exams, and concluded that the money could be spent more wisely on more effective health care services.  In addition,  some experts worry that these potentially uncomfortable exams discourage women for coming in for regular check-ups, which would make the exams more harmful than helpful.  Many experts believe that the time spent doing the exam could be better spent on discussions between the patient and physician about symptoms, health issues, nutrition, or the importance of exercise.

However, the American Congress of Obstetricians and Gynecologists (ACOG), whose members usually perform these exams, disagree, and are still recommending annual pelvic exams for women 21 and older.  Why the different opinion?  ACOG emphasizes that while there is not solid evidence of the benefit of pelvic exams, physicians still find them useful as the starting point for talking to patients about concerns they might not otherwise raise.5  Some physicians believe that women might be more inclined to mention issues such as incontinence or sexual dysfunction during the exam, in response to the doctor’s questions.  If patients don’t need to visit their doctor for an annual pelvic exam, would they go in for an annual exam to talk?  Perhaps not, but is that a good reason to keep recommending an exam that women don’t like and has no clear benefit?  ACOG also recommends a clinical breast exam every 1 to 3 years for women under 40, and then every year afterwards.  That practice is also controversial because there is no conclusive evidence that it helps detect cancer significantly earlier, especially among women undergoing regular mammography.

 

Improving Patient Experience

While the pelvic exam may still be up for debate, there is agreement on a few things.  One is that annual visits to the gynecologist are still a good idea for all women, even if you’re not due yet for a pap smear or pelvic exam.  This visit provides the opportunity to discuss any health concerns, contraception, and to have a general physical exam.          

And, physicians can help reduce patient discomfort during these exams, by conducting the exam AFTER having a conversation with the patient.  For example, some women find the typical reclining position with stirrups embarrassing or degrading.  Studies have shown that women with a history of abuse may experience higher levels of anxiety and discomfort during these exams.6  Having the patient lie on their side or propped up with a pillow, or put their feet at the corner of the table rather than in stirrups can make the exam more comfortable.  Some patients may want to bring a support person such as a friend or partner to the exam, and to wear their own clothes such as a loose skirt rather than an exam gown.

 

Bottom Line

Talk to your doctor about what procedures you want during an annual visit.  Feel free to talk with your physician about whether or not you need an annual pelvic exam, and the potential benefits and risks for you.  If your caregiver wants to perform Pap smears more frequently than the recommended intervals, ask them why.  If you feel anxiety or discomfort with any part of the exam, discuss with them ways to make the exam more comfortable for you.  Sometimes small changes, or finding a physician that you feel more comfortable with, can make a big difference.

 

  1. The American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists: Screening for Cervical Cancer. November, 2012.  
  2. Qaseem A, et al. Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:67-72.  
  3. Myers et al. Management of adnex al mass. Evid Rep Technol Assess (Full Rep). 2006 Feb;(130):1-145  
  4. Adonakis GL, et al. A combined approach for the early detection of ovarian cancer in asymptomatic women. Eur J Obstet Gynecol Reprod Biol. 1996;65:221-5.  
  5. American College of Obstetrics and Gynecology. Committee Opinion. Well Woman Visit. 2012.  
  6. Bates, C, et al. The Challenging Pelvic Exam. J Gen Intern Med 26(6):651–7. 2011.