Recommendations for the routine screening pelvic examination

In March 2016, the Canadian Task Force on Preventive Health Care (CTFPHC) published its recommendations on the routine screening pelvic examination.¹ It recommended not performing a pelvic examination to screen for noncervical cancer, pelvic inflammatory disease, or other gynecologic conditions in asymptomatic women, adding that this is a strong recommendation with moderate-quality evidence. The recommendations did not apply to the Papanicolaou test to screen for precancerous or cancerous lesions of the cervix.² The CTFPHC’s recommendations echo those of the American College of Physicians, which in 2014 recommended not performing screening pelvic examinations for asymptomatic, nonpregnant women based on evidence showing that these examinations did more harm than good.³

These opinions are certainly laudable, for what is the point in performing gynecologic examinations for asymptomatic women if these examinations do more harm than good? Most physicians have been performing these examinations for years, believing that they were helping their patients. The science of medicine is constantly evolving. Often, yesterday’s beliefs turn out to be wrong. Older physicians know this only too well. So if the routine screening pelvic examination is pointless, we should stop doing it.

However, these recommendations raise issues that need to be addressed, as they have consequences that the CTFPHC might not have considered.

First, if we recommend that physicians stop performing gynecologic examinations on asymptomatic women, it follows that family physicians will perform fewer gynecologic examinations.⁴ Many already refer women to a gynecologist for this purpose or put off this examination for all sorts of reasons. Not to mention that compliance with cervical cancer screening programs is already far from perfect.

Performing a good gynecologic examination is not as easy as one might think. It requires dexterity and sensitivity. The less often a physician performs a technique, the less comfortable he or she will be performing it. And as any physician who rarely performs cutaneous sutures or injections or who rarely inserts an intrauterine device will tell you, dexterity and skill can be lost. Logically, physicians who perform fewer gynecologic examinations will also see an erosion of this skill and perhaps also an erosion of the ability to differentiate between what is normal and what is not. Not only will family physicians perform fewer gynecologic examinations, residents will have less exposure to this procedure. Could these recommendations have a negative and unexpected effect on physician competence—and, by extension, on women’s health—over the long term? Time will tell; it is certainly plausible.

Second, the guidelines interfere with daily medical practice. Physicians perform many activities that have more to do with the art of medicine than with evidence-based medicine. If the routine screening pelvic examination is pointless or even harmful, can the same be said of cardiac auscultation and abdominal palpation? If the CTFPHC were to explore this issue, it would probably find little hard evidence of the benefits of these activities. How many cases of lung cancer have we discovered by auscultation of the lungs of our asymptomatic patients? Probably very few. Yet, greeting a patient, observing his gait, deciphering his affect, listening to his heart and lungs, and palpating his abdomen are all part of what a physician does. There are things that we do that simply make good sense and that no scientific evidence will ever prove. After all, we do not need a comparative study to prove the efficacy of a parachute!

Recommending against a routine screening pelvic examination for asymptomatic women interferes with the physician’s judgment. And do not be fooled into thinking that these guidelines are just opinions. They are, in fact, dictates. The words evidence-based medicine seem to carry the weight of absolute truth, yet how many scientific recommendations have failed to pass the test of time?^5,6

While the CTFPHC’s recommendations have merit, clinical judgment still has its place.

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