It turns out that the most uncomfortable and painful part of your annual gynecological exam is also pretty useless. So useless, in fact, that the American College of Physicians, the largest medical specialty organization in the country, recommends that doctors stop performing it.
It's called the bimanual pelvic exam. To get it done, the patient lays on the medical exam bed, naked from the waist down and feet in stirrups. Then the doctor puts gloved, lubricated fingers inside the vagina while simultaneously pressing down on the patient's belly with his or her other hand.
The point of the exam is to try to push both sets of fingers together to meet somewhere in the middle, which allows doctors to evaluate the size and position of the uterus, fallopian tubes and ovaries. (Ow.)
"It's an inherently limited exam, and in asymptomatic people it just doesn't provide any benefit," Dr. Molly Cooke, ACP’s Immediate Past President and a member of ACP’s Clinical Practice Guidelines Committee, told the Huffington Post. "Since the mid-'90s, there have been studies that show the accuracy of the bimanual exam in diagnosing ovarian cancer is extremely poor."
So why are doctors still performing it? People hate change, Cooke explained. Historically, doctors used the bimanual exam to screen for benign lesions and ovarian cancer -- a particularly aggressive form of cancer that is often fatal if it spreads.
But ovarian cancer itself is extremely rare, and the women who are most at risk for developing the disease either have the BRCA gene mutation or have undergone ovary-stimulating fertility treatments in the past, said Cooke. Besides, the most reliable way to diagnose ovarian cancer is through an ultrasound or blood test -- not a pelvic exam.
"The data doesn't support doing this element of the checkup, but a lot of doctors are still doing it," said Cooke. "My own gynecologist still does it!"
The ACP conducted a systematic review of studies that date back to 1946 and summarized the findings in the Annals of Internal Medicine, along with a recommendation against the pelvic exam for healthy, asymptomatic and non-pregnant adult women.
This is a sample of what the study review found:
- Bimanual exams on their own aren't enough to detect cancer. In a large randomized controlled trial involving 78,000 women over a long period of time, researchers eventually stopped performing bimanual pelvic exams five years into the study for precisely this reason.
- In eight surveys involving 4,567 women, participants reported feeling pain or discomfort during the pelvic exam (results ranged from 11 percent to 60 percent).
- In seven studies involving 10,702 women, participants reported feeling fear, embarrassment or anxiety (results ranged from 10 percent to 80 percent).
- Five studies found that women who felt pain and discomfort during the exam were less likely to return to the doctor for a follow up visit.
- There's a dearth of studies on the subject of unnecessary surgeries, except one that indirectly showed pelvic exams led to 1.5 percent of women having unnecessary surgery (29 out of 2,000 people).
- Several studies found that women who had experienced sexual violence in the past also reported feeling fear, anxiety, embarrassment, pain and discomfort during a pelvic exam at higher numbers compared with women who weren't victims of abuse.
In an editorial that accompanied the recommendation, Dr. George F. Sawaya and Dr. Vanessa Jacoby of UC San Francisco wrote that the exam has evolved from evidence-based practice into an unquestioned "ritual" that may in fact harm women more than help them. The harms range from mere discomfort to all the way to unnecessary surgery for otherwise benign growths.
While it's unclear how many undergo an unnecessary surgery, the New York Times reported in 2013 that U.S. rates of ovarian cystectomy and hysterectomy are more than twice as high as some European countries -- perhaps because other countries only perform the bimanual exam on women with other symptoms.
Even if the ACP's recommendation doesn't result in systemic change for gynecologists across the U.S., it should challenge proponents of the exam to come up with clear reasons to continue conducting them, Sawaya and Jacoby wrote.
"The pelvic examination has held a prominent place in women’s health for many decades and has come to be more of a ritual than an evidence-based practice," they wrote. "With the current state of evidence, clinicians who continue to offer the examination should at least be cognizant about the uncertainty of its benefits and its potential to cause harm through false-positive testing and the cascade of events it prompts."
Dr. Ranit Mishori, an associate professor of family medicine at Georgetown School of Medicine and a practicing family physician, was not involved with the ACP's decision, but praised its recommendation and said it was long overdue.
"Many of us, myself included, have already stopped doing these pelvic exams," Mishori told HuffPost. "It's going to make some waves, which is a good thing, but I think it's important as part of a general trend to question rituals that may not have much value."
Other rituals that need to be questioned: the general annual physical itself, according to Mishori. Studies have shown that the appointments may not have much value, especially for people with no symptoms or high risks.
"Years ago, when I went to med school, we were taught the pelvic exam screened for STDS, but we now know we can screen for those things with a urine test," Mishori said. "We once thought a pelvic exam was needed before prescribing birth control, but now we know it's completely unnecessary."
"We need to recognize that a lot of things we do during the annual physical is irrelevant," Mishori added. "Talking reproductive health, there should be a cervical screening every three to five years, and that's it -- nothing else," she concluded.
Instead of taking time for the bimanual exams, gynecologists and primary care physicians would do well to devote two-thirds or even three-quarters of the annual visit to simple conversation, Cooke recommended.
"The visit should spend a significant amount of time making sure our patient isn't smoking or drinking too much," said Cooke. "Does she feel safe in her community, her home and her relationship? Just really connect with that patient as a person." Lifestyle screening, which includes questions about mental health, are much more likely to benefit women more than the bimanual exam, said Cooke.
But of course, just because doctors should do away with bimanual screening for most asymptomatic patients, some women may still have to take their panties off -- even if they fit the bill. Pap smears are still effective parts of the preventive exam for women ages 21 to 65, said Cooke, although the test doesn't need to be done every year.
Cooke anticipates at least some blowback about the ACP's recommendation; for instance, some doctors have expressed fear that patients won't come in for exams at all. She also brought up the possibility that patients might suspect their doctor is short-changing them a bimanual exam on the directive of an insurance company. That's why the ACP wants to get the word out about the recommendation not just to physicians, but to patients, too.
CORRECTION: A previous version of this story misspelled Dr. Ranit Mishori's name. Additionally, it inaccurately described one aspect of the bimanual exam. We regret the errors.