See You Later, Speculum

The case for getting rid of annual pelvic exams.

How often do you really need to get a pelvic exam?

When I was in my 20s and 30s, as for millions of other healthy young women, the only doctor I visited regularly was my gynecologist. I had no medical problems, so I saw no reason to have an internist, even though I had chosen to become one myself. Yet every year I’d dutifully make my OB-GYN appointment and endure the stirrup-and-speculum ritual of the pelvic exam: the circling of the little spatula around my cervix, the twirling of the spiky pipe cleaner, the prodding of my uterus and ovaries. It was always reassuring to get the exam, and equally reassuring to get it over with. Whatever else we discussed—birth control, STD prevention, my diet, stress management—seemed like icing on the cake. The pelvic exam, and in particular the Pap smear, was the main event. Even though I’d probably had close to 20 normal exams by the time I hit 40, it always seemed essential that I get another one every year. And until recently, most other doctors thought so, too.

But an article in Journal of Women’s Health earlier this year declared, convincingly, that the routine kitchen-sink-and-all pelvic exam should be relegated to the medical archives. In a distinct departure from the conventional wisdom, the authors write that there’s no compelling reason why women without symptoms or risk factors should be getting these exhaustive exams—and that even the Pap smear, instilled in the minds of most women over 30 as a necessary yearly ritual, isn’t needed as often as once thought.

Some of the main reasons for conducting a routine pelvic exam are the early detection of cervical and ovarian cancer, screening for chlamydia, and as a prerequisite for prescribing hormonal birth control. But as the Journal article authors note, with the exception of cervical cancer (which we’ll get to in a minute), each of these goals can be addressed with a better or cheaper method—if it needs addressing at all.

To evaluate the ovaries, for example, gynecologists employ the bimanual exam. With two fingers in the vagina and the other hand on the belly, the OB-GYN feels the uterus and ovaries to note the presence of any abnormalities. Unfortunately, there’s no medical evidence that this poking and pressing can reliably detect ovarian cancer in its early stages. In fact, for average-risk women, there’s no good screening test for ovarian cancer—not the bimanual exam (early ovarian cancers are notoriously difficult to feel, which is why they’re often already widespread when diagnosed), nor ultrasounds nor blood tests. Until scientists develop a reliable method of early detection—some ovarian equivalent to the Pap smear, colonoscopy, or mammogram—the best we can do is educate women to report such symptoms as bloating, feeling full quickly, and pelvic pain.

Meanwhile, though chlamydia testing is traditionally done on a cervical sample collected during a speculum exam, a urine sample or a self-administered vaginal swab works just as well and costs less. And although some doctors still insist on a pelvic exam as a prerequisite for prescribing oral contraceptives, there’s no medical reason for that practice. (It’s a different story for an IUD or a diaphragm, which must be fitted to the individual woman.)

Gynecologists take note of many other conditions during the course of a routine pelvic exam. But unless these conditions are causing symptoms—such as vaginal discharge, itching, pain, or bleeding—the information gathered is unlikely to change what the doctor does next. Yeast infections and bacterial vaginosis, for example, usually resolve themselves without treatment. Uterine fibroids may sound scary, but unless they’re causing symptoms (such as bleeding between periods or pelvic pain), there’s no evidence that diagnosing them has any benefit. And while noting the size and position of the uterus makes sense if you’re a medical student studying anatomy, it doesn’t really matter to a doctor whose patient isn’t pregnant and is otherwise healthy.

Even the Pap, long the star of the annual well-woman exam—and one of the most dependable, effective, tried-and-true cancer screening methods of all time—is needed less often than we currently provide it. That’s in part due to the discovery that nearly all cases of cervical cancer are directly linked to infection with certain high-risk types of HPV, or human papillomavirus. During a pelvic exam, a doctor collects cervical cells, which can be “co-tested” for pre-cancerous cellular changes (via the Pap) and, in women between 30 and 65, for HPV. (HPV testing isn’t recommended for women under 30, since the infection is very common at that age and usually goes away on its own.) If a woman’s Pap is normal and she tests negative for HPV, then the chances of her developing cervical cancer in the next several years are incredibly small.

In 2009, thanks to advances in HPV testing and also to years of studies showing that, when part of an organized cervical-cancer screening program, annual testing is no better than less frequent testing, the American College of Obstetricians and Gynecologists recommended reducing the frequency of Pap smears. Assuming a woman’s Paps are consistently normal and that she has no risk factors—such as HIV or a history of cervical cancer—she should have her first Pap at age 21; every two years between the ages of 21 and 29; and, as long as she’s had three consecutive negative Paps, every three years between ages 30 and 65. This prevents unnecessary testing—especially in adolescent women, who despite frequent transient HPV infections rarely get cervical cancer—and overtreatment, with its financial and emotional costs.

For many clinicians long accustomed to the annual pelvic and Pap, it’s been hard to get comfortable with the multiyear recommendation. These exams are, after all, the bread-and-butter of the annual well-woman GYN visit; doctors worry that spacing them out may lead to litigation, difficulty getting reimbursed, and the loss of their primary-care role. And despite the new ACOG guidelines, many doctors remain concerned about whether taking a break is safe, thanks to the long-ingrained notion that annual exams were nonnegotiable. A new reportpublished a few weeks ago in Lancet Oncology may ease that fear: A large study of 330,000 women determined that the three-year interval for Pap/HPV co-testing is, indeed, medically sound. Women who had a normal Pap and a negative HPV test had a very low risk of developing cancer over the following five years: just 3.2 per 100,000 women per year. Compared with breast cancer, where the incidence is about 124 per 100,000 women per year, the risk is impressively tiny.

Some ladies, no doubt, will cheer the idea of spending less time in the stirrups. Others may miss the ritual aspect of the comprehensive exam—the laying on of hands, the time taken to methodically examine, probe, and palpate. But whichever camp a woman falls into, she shouldn’t abandon her yearly well-woman exam, even if she does ditch the annual routine pelvic. If anything, your gynecologist visit will now be even more complete, with time to address a litany of important issues often overshadowed by the pelvic exam: screening for intimate-partner abuse, family planning, physical activity, nutrition, smoking, bone health, breast cancer screening, sexual health, stress management, blood pressure—the list goes on. If the doctor with whom a woman feels most comfortable discussing these issues is her internist, fine. If it’s her gynecologist, why should she stop going simply because she doesn’t need to get on the table? After all, there’s more to screening than a speculum.