Well-Woman Visits Have Become, Well, Confusing!

If you’re confused about the need for annual gynecologic well-woman visits, or what they should include, you’re not alone.

Last July, the American College of Physicians (ACP), a national organization of internists, announced new guidelines that recommend against yearly pelvic exams for low-risk women.

Historically, the pelvic exam has been the cornerstone of a woman’s annual OB/GYN visit. It includes two parts. The first is the physical examination of the external genitalia and the cervix, including the Pap smear, which screens for cervical cancer. In the second part, the doctor uses their hands to feel those pelvic organs that can’t be seen, such as the uterus and ovaries – a process known as examination by “palpation.”

Gynecologists use this palpation examination to help identify pain, masses or other abnormalities which may result in early detection and treatment of pelvic disease. While our hope is to detect the most serious disorders, it is recognized that even the most skilled examiners are often unable to detect cancers of the ovaries, fallopian tubes and uterus with the pelvic examination. The ACP recommendations note that large scale studies designed to address the ability of pelvic examination to detect ovarian cancer have not shown a benefit.

It’s the nature of medicine that some tests, because of their inability to completely rule in or rule out disease, beget more tests. During a pelvic exam, for example, the gynecologist may find an enlarged ovary, which could be caused by a cyst, typically a normal occurrence that is benign (noncancerous) and resolves on its own. The finding may prompt an ultrasound and a follow-up exam a few months later to confirm the cyst did, in fact, resolve itself. In these cases, the patient experiences anxiety and additional costs as a result of a finding during a physical exam – a healthcare experience certainly not limited to gynecology.

There are, however, many pelvic conditions which may be recognized during the pelvic exam that require further counseling, medical or surgical treatment – including in women considered asymptomatic. It is important to note the new ACP recommendation is specifically geared towards these asymptomatic patients.

In general, women are in tune with their bodies. But often what patients consider to be normal changes or insignificant events may actually represent subtle symptoms which may signify disease. Depending on the patient and situation, small discomforts or episodes of nuisance spotting, for example, may not be reported to their gynecologist, but may signal conditions which could potentially be uncovered during a pelvic exam.

In response to the ACP’s recommendations, the American College of Obstetricians and Gynecologists (ACOG) announced it stands by its guidelines, which recommend annual well-woman visits, while acknowledging that no current scientific evidence supports or refutes an annual pelvic exam for an asymptomatic, low-risk patient. ACOG recommends Pap smears every 3 to 5 years, depending on age, past results and type of screening performed.

Here in the division of Gynecologic and Obstetric Specialists at Baylor College of Medicine, our members also continue to support annual gynecologic evaluations. It’s important to recognize that while pelvic exams are a core component of the annual well-woman visit, these preventative health visits are designed to assess and address many other aspects of a women’s health. These include breast health, bone health, contraception, urinary disorders, sexuality, screening for sexually transmitted infections (STIs), immunizations, safety, and evaluation of risk factors for overall health.

We believe the decision regarding the frequency of pelvic examinations should be made jointly by the patient and her physician, after a thorough review of potential symptoms which may indicate pelvic disease.

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