When a girl becomes a woman, she is initiated into a bizarre and mysterious annual ritual. She takes off her clothes, sticks her arms through a backless medical gown, reclines on an examination table, and spreads her legs. A doctor fits her feet into a pair of stirrups, looks at her genitals, sticks a cold metal speculum into her vagina, cranks it open, and peers in. When the speculum is removed, the doctor inserts a finger or two, and pokes around to feel the woman’s internal organs. Sometimes, the fingers examine her rectum, too.
In 2010, doctors performed 62.8 million of these routine pelvic examinations on women across America. In total, gynecological screenings cost the U.S. $2.6 billion every year.
And yet, a new study published in the Annals of Internal Medicine reports that there is no established medical justification for the annual procedure. After scouring nearly 70 years of pelvic exam studies, conducted from 1946 to 2014, the researchers found no evidence that they lead to any reduction in “morbidity or mortality of any condition” among women. In light of the study, the American College of Physicians, a national organization of internists, has crafted a new set of guidelines warning doctors that exams conducted on otherwise symptomless women can “subject patients to unnecessary worry and follow-up” and can “cause anxiety, discomfort, pain, and embarrassment, especially in women who have a history of sexual abuse.”
In an editorial also published in Annals, internists George Sawaya and Vanessa Jacoby of the University of California–San Francisco, conclude that the pelvic examination has “become more of a ritual than an evidence-based practice.” Sawaya told me that the routine pelvic exam is such "a foundational cornerstone" of gynecology, it's hard to even trace its origins. The new report urging doctors to reverse course will be "very controversial," Sawaya says. "I expect a lot of physicians to raise their eyebrows."
Just two years ago, the American College of Obstetricians and Gynecologists admitted that “no evidence supports or refutes the annual pelvic examination … for the asymptomatic, low-risk patient.” Nevertheless, ACOG reupped its endorsement of the exam, writing that it “seems logical.” The procedure—which is routinely initiated early in a woman’s teen years and conducted annually—can aid in “establishing the clinician–patient relationship” and provide “an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks,” ACOG reported. In other words, according to ACOG, while the annual pelvic exam might not be worthwhile in and of itself, it can be a useful device for bringing a woman to her doctor every year to get some necessary information about her reproductive health.
These conflicting recommendations—one by internists, the other by gynecologists—speak to the effects of cultural shaming on women’s health. Some women—particularly women who have been abused—can experience enough anxiety and pain from the intimate exams that they become less likely return for future exams. That could deter women from heading to the doctor when they do have problematic symptoms or heightened cancer risks. Furthermore, women taking birth control pills typically have to undergo an annual pelvic exam before a doctor will refill a prescription, which could prevent some women from using this safe and effective contraceptive method. (The ACP insists that refilling an oral birth-control prescription should not require a pelvic exam.)
Meanwhile, other women experience enough generalized anxiety about their genitals and reproductive systems that the fear pushes them to see their doctors every year and undergo examinations that, it turns out, won’t actually tell them much of anything about their health. While the 70 years of studies parsed in Annals paint an incomplete picture of the full effects a pelvic exam can have on a woman’s well-being, they do suggest that the exams can produce both “false-positive results” and “false reassurance” among women.
The pelvic exam is just the latest women’s health ritual to be reexamined in light of new research. In 2012, the United States Preventive Services Task Force and the American Cancer Society released new recommendations suggesting that women should undergo routine pap smear tests every three years, not once a year. In March, an Food and Drug Administration panel voted to replace the pap smear—in which a doctor scrapes cells from the cervix that are analyzed under a microscope for visual abnormalities—with an HPV test targeted at identifying the strains of the virus most likely to lead to cervical cancer. And in 2009, the USPSTF changed its stance on routine mammograms, recommending that women begin undergoing mammograms at age 50, not 40, and that they do them every two years, not every year.
Proponents of yearly pelvic exams may say that they compel women to seek counsel from their doctors and receive vital information about their own health. (They also, of course, bolster gynecologists' job security.) But it's becoming clear that this line of thinking is self-defeating: There’s no reason for women to report to their doctors every year if they can’t even trust what they’re being told.
What happened to, "First do no harm?"
...and physicians wonder why their patients do not trust them.
There is no reason that a genital exam ever needs to be performed on anyone older than 2 years as part of an annual physical or as part of any other exam in asymptomatic patients. You can not distinguish between the physician who is being "thorough" and a serial sexual predator in the medical setting. In order to protect the patient, it is necessary to err on the side of caution. The patient should be given the option AND allowed to decline this exam without penalty.
The physician's "fiduciary duty" requires the physician to sacrifice his own well being for that of the patient. This justifies the "without penalty to the patient" requirement.