Insufficient evidence supports screening pelvic exams in asymptomatic women, Task Force says

The U.S. Preventive Services Task Force found little evidence on the accuracy of screening pelvic examinations to detect various conditions, including ovarian cancer, bacterial vaginosis, genital herpes, or trichomoniasis.

There is insufficient evidence to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women outside the context of screening for other conditions, such cervical cancer or sexually transmitted diseases, according to the U.S. Preventive Services Task Force.

An analysis by the Task Force found no studies that evaluated the benefit of screening for a range of gynecologic conditions with pelvic examination on all-cause mortality, disease-specific morbidity or mortality, or quality of life, and limited evidence of potential harms of screening. The Task Force recommendation and an accompanying evidence review appeared March 7 in JAMA.

The USPSTF found little evidence on the accuracy of screening pelvic examinations to detect various conditions, including ovarian cancer (four studies, n=26,432), bacterial vaginosis (two studies, n=930), genital herpes (one study, n=779), or trichomoniasis (one study, n=779).

Of the four studies reporting on detection of ovarian cancer, the largest was the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. The ovarian palpation component was discontinued five years into the study because no cases of ovarian cancer were detected solely with bimanual palpation of the ovaries.

The studies that reported on the accuracy of pelvic examination to detect various infectious diseases were all fair-quality. Participants were more likely to represent higher-risk, symptomatic populations compared with women generally seen in primary care. The reported yield of screening was 38.7% to 47.0% of bacterial vaginosis cases, 47.8% of genital herpes cases, and 15.2% of trichomoniasis cases.

There was limited evidence on the harms of screening with pelvic examination, including false-positive and false-negative results. Available evidence reported false-positive rates for ovarian cancer of 1.2% to 8.6% and false-negative rates of 0% to 100%. Pelvic examination screening could also result in unnecessary diagnostic workup and treatment, the Task Force found. In the reviewed studies, approximately 5% to 36% of women who had abnormal pelvic examination findings went on to have surgery.

The recommendation stated, “In the absence of clear evidence on the balance of benefits and harms of using pelvic examination to screen for asymptomatic gynecologic conditions, clinicians are encouraged to consider the patient's risk factors for various gynecologic conditions and the patient's values and preferences, and engage in shared decision making with the patient to determine whether to perform a pelvic examination.”

An editorial said that pelvic examination has been a mainstay in the systematic evaluation of these conditions and remains an important tool in the detection and diagnosis of gynecologic malignancy, genital infection, infertility, vulvar disorders, and benign uterine pathology, as well as for assessment for intrauterine contraception.

The editorial concluded, “[E]ven though the USPSTF determined that the available evidence was insufficient to support or refute the annual pelvic examination in asymptomatic, nonpregnant women, it is not clear that the pelvic examination should be abandoned. Women, as patients, should be involved in the decision regarding whether to perform a pelvic examination, and clinicians should not require that the patient undergo this procedure to obtain screening, counseling, and age-appropriate health services.”