ACOG, AAFP & USPSTF Guidance: Still a Role for the Annual Pelvic Exam?

SUMMARY:

In March 2017, the USPSTF released its Evidence Report and Systematic Review on the topic of periodic pelvic exams. The main outcome measures were morbidity, mortality, harms caused by misdiagnoses and diagnostic inaccuracy for gynecologic cancers and conditions. Cervical cancer and STDs were not included as they were already covered in previous evidence assessments. The summary conclusion states

No direct evidence was identified for overall benefits and harms of the pelvic examination as a 1-time or periodic screening test. Limited evidence was identified regarding the diagnostic accuracy and harms of routine screening pelvic examinations in asymptomatic primary care populations.

ACOG released updated guidance, replacing the prior committee opinion, which provides an overview of the well-woman visit. ACOG recommends that a comprehensive history should guide aspects of the physical exam, such as breast and pelvic examination.  In other words, physical exam should be viewed in terms of a comprehensive provider-patient encounter.

The summary recommendations and conclusions include the following

A well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks.

The periodic well-woman care visit should include screening, evaluation and counseling, and immunizations based on age and risk factors.

The interval for specific individual services may differ for individual patients, and the scope of services provided may vary in different ambulatory care settings.

Team-based care, including obstetrician–gynecologists, physician assistants, nurse practitioners, and other health care professionals, may facilitate meeting the needs of preventive care for women.

KEY POINTS:

Comprehensive ‘Well-Woman’ History

When taking a history, obtain the following

  • Symptoms, if any
  • Past history
    • Medical
    • Surgical
    • Social
    • Gyn
      • Sexual health
      • Reproductive health
    • Mental health (use screening tools as appropriate)
  • Medications and allergies
  • Family history (screening tools available – see ‘Related ObG Topics’ below for more information)

Pelvic and Breast Examinations

  • Perform pelvic and breast examinations based on above history and/or symptoms

Risk Factors

  • Assess for the presence of
    • Smoking
    • Poor nutrition/dietary habits
    • Limited physical activity
    • Alcohol intake
  • The above risk factors contribute to CVD, diabetes and malignancies
  • Counsel regarding lifestyle choices and potential impact and overall and reproductive health
  • ACOG has an obesity toolkit (see ‘Learn More – Primary Sources’ below)

Discussion of Reproductive Life Plan

  • A discussion of a reproductive life plan can include
    • Preconception counseling
    • Infertility concerns/assessment
    • Contraception
  • The well-woman visit can be used to discuss issues surrounding perimenopause and postmenopause

Other Professional Recommendations

AAFP in April 2017 released a Clinical Preventive Service Recommendation against screening pelvic exams in asymptomatic women, giving it a Grade D.  AAFP acknowledges that their recommendation differs from the USPSTF.  The guidance states the following

The USPSTF’s review did not include screening for ovarian cancer, cervical cancer, gonorrhea, or chlamydia, as these are already covered by other USPSTF recommendations. Yet malignancy and pelvic inflammatory disease are the leading gynecologic causes of morbidity and mortality in women. Screening for other conditions that have limited effect on morbidity or mortality are unlikely to provide substantial benefit. There is evidence of harms for performing screening pelvic exams in asymptomatic women due to the increased risk of invasive testing and unnecessary treatment.

The SOGC in August 2019 released evidence-based guidance and similar to ACOG, recommends taking in to account history and physical when assessing the role of pelvic examination. Furthermore,  the SOGC guidance states that

No study published to date has adequately evaluated any component of the pelvic examination as a screening method for any type of malignant gynaecologic disease, except for the speculum examination for cervical cancer cytology screening. As such, any universal recommendations for or against pelvic examinations for other indications can only be made based on expert opinion and low-quality evidence

Learn More – Primary Sources:

USPSTF: Periodic Screening Pelvic Examination – Evidence Report and Systematic Review for the US Preventive Services Task Force

ACOG Committee Opinion 755: Well-Woman Visit

AAFP Clinical Preventive Service Recommendation: Screening Pelvic Exam

SOGC Guideline 385: Indications for Pelvic Examination