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Routine Pelvic Exams are Unnecessary
July 1, 2014 10:59 PM   Subscribe

The American College of Physicians admitted Monday that pelvic exams are not a useful screening tool for healthy women, and can even be harmful. Although these exams are often still required for hormonal contraception, there is no medical reason to do so, and pelvics are often a significant barrier to birth control access. They are not an effective way to diagnose ovarian cancer either, and urinalysis is a better way to detect STIs. The American College of Obstetricans and Gynecologists disagreed, but acknowledged that the case for pelvic exams "lacks data." Pelvic exams are so anxiety-inducing, uncomfortable, or painful that they can even cause some people to avoid medical care altogether, yet both clinicians and patients are so resistant to change that it's likely millions of women will continue to be screened despite the lack of evidence of benefit.
posted by Violet Hour (96 comments total) 40 users marked this as a favorite

 
I started to put together an FPP on this but ran out of time, so I was happy to see this appear. Reading the first articles on this brought back memories of how much my first serious girlfriend dreaded these exams and how much pain and discomfort she went through because she was told it was important:

“We did find some evidence that the exam caused fear, anxiety, embarrassment, and discomfort in women and may be preventing some from getting medical care.”

If the costs are outweighing the benefits, then the protocols should change.
posted by Dip Flash at 11:25 PM on July 1 [1 favorite]


I dread the old annual pelvic exam. I'm anxious for days beforehand. During my most recent exam, I asked my gynecologist about a report I'd heard that the HPV test was just as effective for detecting cervical cancer as a Pap smear. He said that the prior week he had a patient who was diagnosed with a cervical cancer that wasn't caused by HPV and was only caught by her Pap smear. I guess I'll keep suffering through it.
posted by cherrybounce at 11:26 PM on July 1


This is kind of a fightily simplistic way to present what is ultimately a very complex statistical, medical, and philosophical question.
Making Sense of Screening [PDF]
A guide to weighing up the benefits and harms of health screening programmes
Public expectations about screening don't match what screening programmes can deliver. By addressing misconceptions about how screening works, its limitations and the calculation of benefits and harms, scientists and clinicians hope to bridge the gap between the active debates of the scientific community and the concerns raised by the public.
posted by Blasdelb at 11:26 PM on July 1 [13 favorites]


Blasdelb, the above link is great, but the problem is that pelvic exams aren't really necessary to test for anything specific.
posted by Violet Hour at 11:50 PM on July 1


[Just a quick note/reminder here: OP, you've presented your post in a fairly one-sided way, and people are now allowed to comment and offer other arguments, if they come up. We do ask that posters not threadsit their own posts to try to dominate and steer discussion. Thanks.]
posted by taz at 12:09 AM on July 2 [5 favorites]


See also: prostate and breast screening. There is often a profoundly counter-intuitive aspect to screening, because even where cancer is located sometimes the overall rate of survival doesn't change with or without the procedure.
posted by Sebmojo at 12:15 AM on July 2


I guess there is also the potential threat of false positive results: “U.S. rates of ovarian cystectomy and hysterectomy are more than twice as high as rates in European countries, where the use of the pelvic examination is limited to symptomatic women.”
posted by rongorongo at 12:28 AM on July 2 [3 favorites]


Cherrybounce, that's one of those really rare cases like when someone goes to the doctor for a migraine with no other symptoms but gets an MRI because they insist and gets diagnosed with a brain tumor. It would still be really bad for doctors to insist on MRIs for all migraine patients, because MRIs carry their own risks and the cost/benefit just doesn't work out.

The cost/benefit of pelvic exams changes when you add previously overlooked costs to the equation: patient distress and discomfort and patients refusing to see a doctor because of the pelvic exam which appears to be a quantifiable statistical cost.

So for every woman your doctor found a rare type of cervical cancer only diagnosable by PAP smear that year, you'd have a bunch more women who avoided the doctor's care entirely because they find the annual pelvic exam terrifying or painful.
posted by viggorlijah at 12:39 AM on July 2 [11 favorites]


I dread the old annual pelvic exam. I'm anxious for days beforehand. During my most recent exam, I asked my gynecologist about a report I'd heard that the HPV test was just as effective for detecting cervical cancer as a Pap smear. He said that the prior week he had a patient who was diagnosed with a cervical cancer that wasn't caused by HPV and was only caught by her Pap smear. I guess I'll keep suffering through it.

"It is difficult to get a man to understand something, when his salary depends upon his not understanding it." --Upton Sinclair

Most if not all (99.7%) cervical cancers are HPV positive.
posted by benzenedream at 12:40 AM on July 2 [8 favorites]


So in this case the ACP has specifically separated Cervical Screening from the routine pelvic exam.

They still believe in the cervical screening programme and they're not saying that should be stopped. In the UK this programme often only requires smears once every three years if you've only had normal results. I wouldn't be too surprised if it was the case in the US too. So you should still get your smears!

What they are saying is that separate from the smear the routine bimanual and I guess even visualising the cervix is of little clinical use if the patient is asymptomatic. In fact they argue it causes more harm - through anxiety and stress of patients undergoing the procedure and through falsely identifying problems where there are none or providing false reassurance.

As an interesting side note: the detection of actual real cancer on a smear is a failure of the screening programme. It exists to detect precancerous lesions before they become cancerous, and it really targets HPV like precancerous lesions. They do look for other markers but they're less specific and sensitive than the HPV ones so more false positives and false negatives.

And as a slight derail: there is a huge question about what will happen to the efficacy of the cervical screening programme once the vast majority of women have the HPV vaccine.

If the vaccine works we should reduce the incidence of cervical cancer drastically. At that point the risk of falsely identifying a smear as positive will outweigh the likelihood of detecting a true positive meaning we'll be overtreating vast numbers of women and the benefits of the programme will not outweigh the costs.

Another possibility is that the vaccine will simply change the viruses that cause cancer to change the appearances on the smear, at which point the programme wouldn't work as well and would give false negatives.

In any case the evidence is still that the programmes are working, so you should still go and get your smear.
posted by zeripath at 12:59 AM on July 2 [14 favorites]


I'm a little uncomfortable with the framing here, as "The ACP admitted Monday" makes it sound as though the ACP was forced by some external agent to acknowledge this as a known problem. Instead, the ACP conducted a very thorough systematic literature review (1946 to 2014!) and published the resulting practice guidelines in its very widely-read and influential journal.

Similarly, the article describing "resistance to change" is based on interviews with 27 Australian GPs, and given the 31% response rate may not accurately reflect Australian perspectives, never mind those of American practitioners and health care system. (A study of 1250 US physicians, Stormo et al, Preventive Medicine, 2012, concluded that the majority of OB/GYNs but not GPs or internists routinely performed pelvics, but didn't assess whether they'd change their practice if presented with evidence.)

I don't disagree with your conclusions, just your emphasis. I do think it's worth specifying again that this guideline applies only to routine examination of asymptomatic, nonpregnant adult women, i.e. as the first screening mechanism for benign and malignant gynaecologic conditions. This doesn't disprove the utility of pelvic exam in diagnosing symptomatic women and in management of pregnancy.

The American College of Obstetricians and Gynecologists is pushing back.
posted by gingerest at 1:07 AM on July 2 [23 favorites]


You know, in other countries we just don't do them. Smear tests yes, diagnostic bimanual exam during pregnancy or if you have symptoms of some sort yes, but mass bimanual exams for every woman every year? No. Crazy Victorian hangover.
posted by tinkletown at 1:37 AM on July 2 [5 favorites]


A routine pelvic exam led to a punch biopsy twice. Both times, the pap smear was actually negative as was the punch biopsy. Two rather painful biopsies and countless pap smear later, they gave me a $10 bottle of antibiotics and called it a day. Fuck pelvic exams.
posted by Foam Pants at 1:47 AM on July 2 [4 favorites]


I really like my GP. She can be a little brusque, but she's always on time, and she treats me like an adult who isn't faking or exaggerating my chronic health issues. This is rare.

The one exception is that each time I go, she pushes me to schedule a pelvic exam. I've never had one. I've never been sexually active, am not planning to be in the near future, and I've never had any symptoms of a problem.

I've always had serious questions about their usefulness (especially for someone like me), and I think I've commented here before that the requirement that a woman have one before being given hormonal birth control is an appalling practice. Women are coerced into an uncomfortable, intimate procedure that is not necessary to evaluate risks of taking the medication, which would be the only possible justification for the requirement.

This year I finally caved and scheduled one. I've been considering cancelling it. Finding out that it's an American hangup is really eye opening.
posted by Kutsuwamushi at 2:47 AM on July 2 [8 favorites]


The other issue with the pap smears is false positives. I had one back in the late 90s, and had a painful colposcopy that determined that I had no HPV or gynecological problems. And of course, when I was giving birth to my daughter and my cervix wasn't opening up, I learned from the nurse in the birthing room (the doctor had mysteriously never mentioned it) that women who have had colposcopies often have difficult births because the cervix doesn't open consistently and/or has other problems.

I often think back to my false positive pap and wonder why my gyno immediately ordered the colopscopy rather than running a second pap a month or so out.

My cervix was pretty beat down. To learn that the pelvics aren't necessary reinforces my frustration with the gynecological care I've received.
posted by miss tea at 3:07 AM on July 2 [1 favorite]


I was surprised about the 'resistance to change' article being from Australia because I have never, ever had a pelvic exam (as distinguished from a pap smear) nor had one suggested from a GP. I move a lot and have seen a lot of different doctors. I was under the impression it was a US thing, like going to a gyno for routine stuff aka 100,000kms service.

Although this post did prompt me to update my address with the Pap Smear registry - the service that writes to you and says 'hey, it has been a few years... think you should get a pap smear or what? And I'm like 'I dunno, I'll ask him but I think he plays for Foo Fighters now' and it is red wine weather in Australia tonight and I'll see myself of this thread.
posted by Trivia Newton John at 3:30 AM on July 2 [6 favorites]


From one of my FB friends:
American College of Gynecologists: Confining a woman in stirrups and inserting a metal tool in her vagina helps in "establishing the clinician–patient relationship” and is “an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks.”

How about chatting over a nice cuppa tea, instead?
posted by Etrigan at 3:58 AM on July 2 [28 favorites]


I've wondered how often child exams are useful as well in terms of actually catching diseases that kids wouldn't mention symptoms of anyway. I thought those were traumatic!
posted by xarnop at 4:07 AM on July 2


Fuck this "oh it's embarassing, or ouchy, or whatever" shit. I now have multiple friends whose serious and nearly life-ending cancers were caught by their annual exams. We are all under 40. We are all otherwise more or less healthy. Two of them would NOW BE DEAD if they hadn't gone. And I only found out my grandmother died of ovarian cancer (not lung cancer, as I'd been led to believe) when I had a scary exam of my own that warranted further followup.
posted by bitter-girl.com at 4:56 AM on July 2 [5 favorites]


I dunno. The thing that saddens me about this whole issue is that the consternation seems to be about the medical establishment, and not the utter, utter heartbreak that women are so ashamed and terrified about letting their physicians examine their genitals. How many of us get that freaked out if the doc looks in our mouths, listens to our hearts, checks our knee reflexes? How many of us are wigged out for days beforehand that the doc might see our noses and elbows?

Yes, I get that everyone needs privacy and bodily autonomy, but I think this speaks more to the massive cultural shaming about female sexual anatomy and sexuality, still so pervasive, still hugely impactful in many realms in womens' lives, including health. Makes me really sad.
posted by Sublimity at 5:03 AM on July 2 [30 favorites]


The thing that saddens me about this whole issue is that the consternation seems to be about the medical establishment, and not the utter, utter heartbreak that women are so ashamed and terrified about letting their physicians examine their genitals.

This is how it struck me, too. I'm in no way lessening the legitimacy of those feelings, but if it has any value and what "outweighs" that value is that it causes fear and anxiety and misery, that's sad. (Not in the "that's sad; you're wrong" way. Just in the "that's sad" way.) I mean, does that mean if you don't find it a terrible experience and consider it a minor inconvenience, there may be admittedly minor benefits that are still worth that minor inconvenience?
posted by Linda_Holmes at 5:10 AM on July 2 [3 favorites]


And I only found out my grandmother died of ovarian cancer (not lung cancer, as I'd been led to believe) when I had a scary exam of my own that warranted further followup.
Ovarian cancer sucks beyond the telling of it, but part of the reason that it's so lethal is that there isn't any good diagnostic procedure that will catch ovarian cancer early enough to treat it. It's not like you just need to submit to some shitty procedure and you can reduce your risk of dying of ovarian cancer. It's that the shitty procedure still won't catch ovarian cancer, and we need more research to figure out how to diagnose and treat that kind of cancer effectively.

Having said that, cervical (unlike ovarian) cancer is one of the great success stories of modern public health. It went from being a major killer of young women in the developed world to being a fairly rare and almost totally preventable cause of death. It's also, strangely, a success story specifically for the American medical system, as demonstrably awful as our medical system may be. American women are less likely to die of cervical cancer than Danish, British or German women are. We're even slightly less likely to die of cervical cancer than women in Canada, Sweden or France. We probably over-test in general, and maybe it's not worth it to save a couple of hundred women a year. But I'm really hesitant to throw out something that really seems to be working.
posted by ArbitraryAndCapricious at 5:13 AM on July 2 [9 favorites]


"and not the utter, utter heartbreak that women are so ashamed and terrified about letting their physicians examine their genitals." I dunno. I don't get the same feelings when people touch my knee or my elbow.

I think it should be ok for people to not want other people in their sexual parts unless it's really necessary to treat or prevent a disease.

The sentiment that people should feel the same about being touched in the genitals vs other parts of the body doesn't make sense to me. Most people don't feel that contact with their genitals carries the same sexual energy or vulnerability as other parts of the body and I don't know that body pride means that has to change?

There's nothing wrong with being comfortable being naked or with being someone who doesn't feel particularly vulnerable or uncomfortable with genital contact or penetration but it's really not the same thing as having someone check your mouth or your ear for most people.

I understand why some people would feel totally comfortable with it, I just also understand why some people would not ever be even if they totally love their bodies. To me, it reminds of the really awkward positions I get put in where I might be feeling sexual and want AWAY from that and yet I am told because the other person doesn't feel it's sexual I shouldn't be able to say that I want a boundary there because for ME that's a sexual experience and a part of me I want to choose who I get to share it with.
posted by xarnop at 5:25 AM on July 2 [9 favorites]


It is my body and my money. I should get to decide if I get an uncomfortable exam that is apparently not very useful as proven by scientific research (not anecdote), right?

Oh, sorry. I forgot that this is America and expensive, medically unnecessary tests are de rigueur here.
posted by sockermom at 5:27 AM on July 2 [4 favorites]


Yeah, and that shit hurts me really bad for me as well. There are many reasons it's not the same thing as just having your nose checked or something. I think if they have a lot of evidence behind them in terms of diagnosis and treating conditions it could be worth it, but I think this is a good time to evaluate how often or when there really are benefits to this.
posted by xarnop at 5:31 AM on July 2


American women are less likely to die of cervical cancer than Danish, British or German women are. We're even slightly less likely to die of cervical cancer than women in Canada, Sweden or France. We probably over-test in general, and maybe it's not worth it to save a couple of hundred women a year. But I'm really hesitant to throw out something that really seems to be working.
They are just as likely to die from it as Dutch women though (according to this). In the Netherlands women over 30 get a pap smear every five years, and that's it. I had never even heard of pelvic exams before reading about them on Metafilter.
posted by blub at 5:47 AM on July 2 [2 favorites]


Having defended the American testing regime, I guess I'm thinking more about routine paps being strongly encouraged, rather than pelvic exams. But the idea that an annual pelvic promotes "intimacy" between doctor and patient sounds absurd to me, as does the idea that women are somehow going to let their guard down and share medical details during a pelvic that they wouldn't share during a routine office visit. In fact, I think that anxiety about getting an exam might cause women to be less forthcoming. I don't think I'm a particularly high-anxiety patient when it comes to gynecological care, but I'm pretty much just thinking about getting the damn thing over with, and once I've got my clothes back on, I'm thinking about getting out of the doctor's office and rewarding myself with a latte. I'm not going to say "while you're poking around in there, I have some questions about my lady bits."

I had my annual last week, and I saw a resident, because I get care at a teaching hospital. I go to a gynecologist, not my GP, because I have serious menstrual issues, for which I take hormonal birth control. The resident very seriously informed me that she wasn't sure it was a good idea for me to be on the pill, because I had high blood pressure. And I was like "what are you talking about? I don't have high blood pressure." She showed me my blood pressure reading that the nurse had just taken, which was slightly high, and I was like "yeah, I think that might just be because I'm about to have a pelvic exam." She seemed totally skeptical and was really surprised when she took it again at the end of the visit and my blood pressure was normal. So do they really not teach these folks that women are anxious about pelvics? Heck, did she not know that from personal experience? It sometimes feels like doctors are aliens who have never had a conversation about medical care with an actual woman.
posted by ArbitraryAndCapricious at 5:53 AM on July 2 [13 favorites]


I can think of several medical exams I find approximately as invasive/painful as these exams. The difference is that THOSE medical exams were actually medically necessary for diagnostic purposes.

For a non-genital example: I really hate having my ENT reach into my throat with her gloved hand and palpate my tonsils. It is really freaking unpleasant. Based on my informal survey of telling people about this procedure, I'm guessing most people, male and female, would really hate this exam. In my case there's a medical reason and I put up with it, but if I didn't have said medical reason, no way in hell would I be doing that test, because there's no freaking purpose to it unless you have symptoms that require it.

If the test serves no purpose, or has a negative net benefit, then it shouldn't be done as a standard thing. (I mean, nobody is saying people can't volunteer for the exam, or ask their doctor for it. What they're saying is that it shouldn't be required as an annual exam if it drives people away from the doctor's office, which is what is happening now.)

And again, this isn't a recommendation against Pap smears -- still recommended, but generally at some longer interval than annually -- or exams in cases where a woman is symptomatic -- still recommended. There are valid diagnostic purposes to these exams in those situations. But that doesn't mean they're necessary in asymptomatic women, on an annual basis.

As for ovarian cancer, I thought that was diagnosed via blood test or trans-vaginal ultrasound these days?

(Also, this particular exam isn't "getting your nose checked", it's more "having a doctor stick a camera down your nose and look around with only a topical anesthetic" which is also pretty unpleasant and is also only done when there are actual medical reasons to do it. Although in my experience doctors are much more sympathetic about sticking a camera down your nose. But I digress.)
posted by pie ninja at 5:56 AM on July 2 [1 favorite]


I was so glad to get my hysterectomy because it meant no more pelvic exams (among other things.) I was sexually assaulted as a child, and while I can intellectually reassure myself that the doctor with the cold, painful, medical tool down where I can't see her isn't doing anything bad, it feels bad.

On point, I also feel this way about going to the dentist. Having hygenists and dentists leaning over me, pulling and manipulating my mouth in a way I only intellectually understand is terrifying.

I have to take Xanax to go to the dentist, because I would like to keep my real teeth. But boy howdy, I'm glad I don't have to take a Xanax and get a pelvic or pap anymore.
posted by headspace at 6:04 AM on July 2 [5 favorites]


They are just as likely to die from it as Dutch women though (according to this). In the Netherlands women over 30 get a pap smear every five years, and that's it.
The Netherlands also has a vastly superior medical system which makes it much, much easier for women to get medical care. You have much better outcomes than the US in most areas. And we match you on this one, even though the people most at risk for cervical cancer are young adults, which is to say members of a particularly under-served demographic in the US system. There are a lot of reasons for this, including that places like Planned Parenthood put a huge amount of effort and resources into providing affordable gynecological care for women who otherwise might not have access. But a lot of the reason is that in the US, access to hormonal birth control is contingent on getting regular Pap exams. If we get rid of that, then more women will get cervical cancer, and some of them will die of it.

Obviously, I would prefer to have a system like the Dutch one and encourage preventative care by making access easy and universal. But as recent history has shown, that's a really difficult thing to accomplish in the U.S.
posted by ArbitraryAndCapricious at 6:06 AM on July 2


Part of the reason a lot of women (and probably some trans men too, though I can't speak to that experience) hate these exams is because their physicians already fail to take them seriously, shame them about their "unhealthy habits" (including for their size and for sex), and generally have a combination of shitty bedside manner and sexism. It's not just women having leftover societal hangups about genitals, it's specific dread related to their experience with doctors.
posted by NoraReed at 6:07 AM on July 2 [22 favorites]


Although in my experience doctors are much more sympathetic about sticking a camera down your nose.

That's an interesting observation! I've been fortunate enough to never have to deal with that (as I cross my fingers and hope this isn't the year my tonsils/respiratory system suddenly betrays me), but that makes sense in the context of the interesting conversation I had with a GP this year. I threw an absolute shitfit in response to coercion from the GP to get a pelvic before she would allow me a new prescription for the pill. The last argument she used before I walked out the door and changed practitioners was that since I allow my husband to penetrate me, I should be TOTALLY COOL with allowing her to do so for kicks. I just...what? No. That's not how that works.

But I guess by that logic, yeah, most people don't allow people to stick things in their noses for non-medical reasons and could be reasonably expected to be uncomfortable with it. Still, for all the medical professionals I know who are incredibly empathetic people, I seem to always wind up with the ones from Mars.
posted by bowtiesarecool at 6:08 AM on July 2 [2 favorites]


Let's be careful to distinguish between the pelvic exam and just the pap smear. The pap every 3 yrs (for cervical ca screening) is still recommended; it's the annual pelvic exam (for ovarian ca screening) which is being called into question.

[For the men in the room: The pap is an invasive and uncomfortable/painful swab -- think of a strep test but with a speculum. It has predictive value as a cervical cancer screening tool, is relatively quick, and is only done once every three years. The annual pelvic exam is a longer, more intimate examination of the internal organs -- including palpation w. fingers (see #10,11) & longer/more painful use of the speculum -- and is not an effective screening tool for ovarian cancer (because, unfortunately, nothing is).]
posted by Westringia F. at 6:22 AM on July 2 [7 favorites]


On the doctor sympathy and nose vs. ladyparts front: I think also it's partly that the pelvic is considered "routine" and as such there's a lot more "Suck it up, everyone does this, and you've had this before" about it, while the nasal endoscopy is a non-routine procedure that people generally haven't had before. But I still find the difference between the sympathy levels for the two tests really weird.

But a lot of the reason is that in the US, access to hormonal birth control is contingent on getting regular Pap exams. If we get rid of that, then more women will get cervical cancer, and some of them will die of it.

But this isn't about Paps -- this is about routine pelvic exams when a Pap is not required (e.g. annual exams, the Pap recommendation is generally a longer interval).

Also, while our cervical cancer outcomes may be the same, what about our outcomes for everything else? All the stuff that doesn't get assessed because women are avoiding the doctor because they don't want the annual pelvic? You can't just weigh cervical cancer outcomes -- you also have to weigh all the other possible outcomes from other health areas that aren't being assessed in the women who are staying away.

My personal preference is for a doctor who recommends tests, and explains why they are recommended, but respects me if I say I'm not willing to do them. For example: my dentist tries to X-ray my teeth every 12 months and I only let her do it every 18-24, in accordance with the ADA recommendations for adults without other risk factors. She doesn't refuse to treat me for this -- she explains her logic, I explain mine, I don't get the X-ray, and we both move forward with my dental care.
posted by pie ninja at 6:25 AM on July 2 [3 favorites]


I want to respect the experience of the people who've had cancers detected through pelvic exams... but does it have to hurt so much?

Out of the corner of my eye, I saw the doctor performing my first pelvic exam lean forward and tense up as though she were about to fast-pitch a softball, and was like "what? Why?" Why did she need to dig around so hard? I bled after that. I couldn't sit down easily for a week afterwards. I started having nightmares about the exam. Even now I can affirm the medical importance of the test, but I can't stop crying while I do it. I would love to make it easier on myself, but I don't know how.
posted by koucha at 6:27 AM on July 2 [3 favorites]


i am also a sexual abuse survivor and pelvic exams or dental exams are really awful for me. this isn't some sort of victorian body shame reaction. having your vagina forced open with a speculum, then having your cervix rubbed raw with a giant qtip is really not comparable to having your ears or elbows checked.

also, like norareed points out, some of these doctors are total asses about a great many things. during my last pelvic exam i was mocked for doing my own cervical check and told i was wrong about having felt bumps because she didn't see anything like that (thanks to the internet i know they aren't a big deal).
posted by nadawi at 6:30 AM on July 2 [4 favorites]


Comparison to a nasal endoscopy is good in terms of the relative invasion and pain.

But if I had to have the endoscopy every year, I'd sure be rationalizing ways to avoid it, yes. Which is part of the point here.
posted by Dashy at 6:31 AM on July 2 [1 favorite]


As a formerly many year grad student, and thus a many year veteran of campus student health clinics, I would also point out that there are plenty of doctors who are still refusing to prescribe contraception without annual Pap smears. The every three year guidelines have not trickled down to all doctors for that yet. I can't imagine how long it will be before they would even consider not doing a pelvic exam every year.
posted by hydropsyche at 6:32 AM on July 2


I want to respect the experience of the people who've had cancers detected through pelvic exams...

Experience is important, but it doesn't tell us whether or not a method is effective when implemented across an entire population. This is very similar to the mammography issue that came up in the past couple of years. In a sample size of 90,000, the use of mammograms to screen for breast cancer did not improve the survival rates - and yet, following the results of that study, many people said that they were going to ignore the science and continue baseless recommendations for frequent mammograms.

We need medical recommendations that are based on what works on a population level, not on what makes a person feel good.

My sweetheart went to a doc recently to have a wound looked at - she thought it was getting infected. The doc told her, "It's not infected, but if you'd like, I can prescribe you antibiotics."

This isn't about making people's singular experiences feel good - that's a different realm of medical practice. When it comes to how doctors treat people, recommendations need to be based in what science tells us about the broad-scale effectiveness of certain interventions.
posted by entropone at 6:49 AM on July 2 [8 favorites]


I'm not that hung up about my doctor's view of my sexual activities (I'm a boring married person) and I like my doctor, and my exam isn't due until something like November, but damn if just reading about the annual exam doesn't make me tense up. It's really unpleasant and nasty and if it's not medically necessary, I'd be more than happy to see the back of it.

(And yes, I've known a family friend who died from ovarian cancer. She couldn't be bothered to be treated for actual pain while her husband was ill and it cost her her life. Don't do that.)
posted by immlass at 7:17 AM on July 2


I'm a man but have an interest and personal connection to women's health issues, so I'm interested in this but don't have a dog in this fight, so to speak, but I just wanted to point out that if you're experience with these type of exams is limited to mild discomfort, your experience may not be universal.

Women with histories of sexual abuse are going to have a drastically different relationship to being strapped into a chair with their legs spread and be digitally penetrated. Its definitely worth acknowledging that, and its a medical issue in itself.
posted by MisantropicPainforest at 7:26 AM on July 2 [5 favorites]


This isn't about making people's singular experiences feel good - that's a different realm of medical practice. When it comes to how doctors treat people, recommendations need to be based in what science tells us about the broad-scale effectiveness of certain interventions.

The fact that you think these are two separate things betrays a profound misunderstanding of how medicine and the treatment of patients actually works.
posted by MisantropicPainforest at 7:27 AM on July 2


To clarify: I don't think what seems sad is that people would prefer not to have them. I think what's sad is the description of anxiety and misery and dread. While certainly some of that anxiety and misery and dread comes from simple preferences about privacy, some of it comes from traumatic experiences I wish hadn't happened, bad doctors I wish hadn't come along, and lousy care that I wish people hadn't gotten. That's all.

Its definitely worth acknowledging that, and its a medical issue in itself.

Of course. Of course. But the experience of it being traumatic and anxiety-producing isn't universal either. These reactions are personal; everybody's reaction counts and is real. It's tricky that broad recommendations about screening tests are (as they inevitably must be) based in part on negatives that don't apply to everybody.
posted by Linda_Holmes at 7:29 AM on July 2 [2 favorites]


Benzenedream and viggorlijah, how do your figures about percentage of cervical cancers caused by HPV match up with this report from the WHO?
Thanks!
posted by cherrybounce at 7:37 AM on July 2


I'm always encouraged to see people striving towards the practice of evidence-based medicine. But also, I used to feel like my lady business was shameful and gross. Breast exams and pelvic exams gave me the impression that those body parts are could kill me and were for men's enjoyment only. Especially when it seemed like every boyfriend I had offered to do a breast exam on me. SO CLEVER.
posted by kat518 at 7:41 AM on July 2 [2 favorites]


The fact that you think these are two separate things betrays a profound misunderstanding of how medicine and the treatment of patients actually works.


That's unnecessarily argumentative.
posted by entropone at 7:44 AM on July 2 [1 favorite]


Also: women who are anxious about it (for any reason) are more likely to experience more extreme physical pain as a result of vaginismus, a involuntary tensing reflex akin to shutting your eyes to protect them. And the pain of that experience leads to more anxiety next time, causing yet more pain, &c.
posted by Westringia F. at 7:44 AM on July 2 [2 favorites]


I've been in a monogamous relationship for six years now and we're still using condoms because I have so much anxiety about the steps required to be prescribed hormonal contraception. I did go on the Pill once. I lied about when I had become sexually active so that the doctor wouldn't know I was long overdue for a pap smear etc. When the prescription ran out, I never went back, because I wouldn't have gotten away with that again (she wrote me a prescription, but also a note that I needed a physical exam sometime in the near future). So back to condoms it was.

I'm not a fan of physical exams as a prerequisite for access to contraception. I know that pap smears and all are important, and I definitely do hope that at some stage I will be able to work through my anxiety about them. But for now, my own personal risk/anxiety calculus works out such that I'm still just going to take my chances. And I am relatively well informed about sexual health, certainly well enough to know that I'm making a decision many or most people would see as stupid. But I don't believe that that decision should be 'punished' by restricting my access to contraception. Now, I also have a higher risk of unplanned pregnancy, in addition to greater risks wrt cervical cancer.

But I'm fortunate. I'm not in any risk populations, demographically speaking. I have easy and cheap access to quality medical care. I've never been sexually abused. If I'm making these decisions, I'm sure that so, too, are many more women who do not have these advantages.

And my partner has been willing to use condoms correctly and faithfully for six years. In our social context, this is definitely not the norm for long-term monogamous relationships. For many of the women most at risk of not accessing regular gynaecological care, this will not be true of their relationships. For me, a personal decision that undergoing pap smears and pelvic exams is not worth it means no access to hormonal contraception. For lots of women, it likely means a lack of access to contraception altogether.
posted by lwb at 7:57 AM on July 2 [1 favorite]


Truth be told, that's a big part of the reason I got an IUD. But to anyone here who faces this dilemma: you should know that PP will write pill scripts without a pelvic exam. It's a program HOPE: Hormonal Options without Pelvic Examination [pdf of intake form].
posted by Westringia F. at 8:00 AM on July 2 [4 favorites]


Cue the wailing from people who have no idea that for any medical intervention there is a trade-off between risks and benefits:

"Routine screening has no benefit in healthy women? But my friend's life was saved because [X] was diagnosed during her pelvic exam before getting birth control pills."

And the ranting and raging from anti-government types:

"This is just socialist rationing of health care! They just want to let people die of ovarian cancer because they'll cost the system less!"

Straw women? I wish. I remember the outrage that spilled forth when some new advice came out about who really benefits from screening mammography.

For a lot of screening tests, there are a few big winners (those who actually got diagnosed with a serious problem and whose life will actually be prolonged if they get proper treatment) versus a lot of little losers (who get no benefit, but who spend their time and money, undergo pain or anxiety, have a false-positive, etc.)
posted by etherist at 8:00 AM on July 2 [1 favorite]


More about Planned Parenthood's HOPE (Hormonal Option without Pelvic Examination) program. They'll still urge/browbeat you about getting checked in the future, but they will give you the pill without it. Don't let the pelvic exam stop you from getting the contraception you want!
posted by Westringia F. at 8:07 AM on July 2 [2 favorites]


Ovarian cancer survivor here. Neither I nor any of the other women I've met who've had it, were diagnosed as the result of a pelvic exam, routine or otherwise. Once other conditions that might cause my symptoms were ruled out, the big clue came in blood tests and the tumor was discovered via abdominal ultrasound. The only pelvic exams I had during my entire treatment were to make sure that the post-op vaginal cuff had healed properly.
posted by The Underpants Monster at 8:08 AM on July 2 [5 favorites]


their physicians already fail to take them seriously, shame them about their "unhealthy habits" (including for their size and for sex), and generally have a combination of shitty bedside manner and sexism.

Yes yes yes yes yes yes. This point resonated with me enough that I am actually tearing up right now; doctors, especially but not exclusively gynecologists, routinely make me feel TERRIBLE about myself and my choices (and things that aren't my choice like having a thyroid problem or whatever). In the interest of treatment and health outcomes I have to tell them what medicines I take which include medicines for bipolar so yay another chance for me not to be taken seriously.

Basically, for me at least doctor's offices are profoundly not safe spaces and I routinely cry either at the appointment or after. Being in an environment where I feel unsafe and judged then having to make myself even more vulnerable doesn't feel good. Yes, I feel full of shame about my body, but it's not just society, a fair amount of it comes directly from the doctors who are trying to help me.
posted by Mrs. Pterodactyl at 8:32 AM on July 2 [8 favorites]


Cherrybounce, that's 70% for two of the HPV virus variations. Add in the other variations of HPV and virtually all cervical cancers are linked to HPV. (Source)

I have come close to punching a nurse so far once in my life over a forced by law pelvic for a sexual assault survivor I knew with unsympathetic medical staff. I've had another required pelvic (although in hindsight, we should have skipped it with the new standards) for another survivor where with helpful medical staff and lots of communication, it was bearable and helped.

Also, I wonder about infection rates. I refused pelvic examinations from my third trimester on medical grounds - I think it was relatively new because I had to argue with some staff over this as a check for dilation. The balance of introducing an infection (even with sterile gloves etc) over any real medical information gained vs ultrasounds etc was too high.

And yes - a cursory google search for infections post-pelvic exam shows multiple papers reporting an increase.
posted by viggorlijah at 8:37 AM on July 2 [3 favorites]


This is good news as is any data which lets us reduce the number of expensive, unnecessary, and uncomfortable medical tests and exams we must endure! Now if only they would discover that manual prostate exams are likewise deprecated. Because I'm not getting any younger over here.
posted by Justinian at 8:53 AM on July 2


I wonder why the idea that "pelvic exams MUST be painful and unpleasant" has gone unquestioned for so long.

After all, dentists have figured out that making dental procedures less of an ordeal means that people will visit the dentist more. Dental visits now are such a far cry from the ones of my childhood that there is no comparison. Not that I go to the dentist as recreation, but my own dentist and her staff do everything they can to respect their patients, treat them well, and make dental visits and procedures something to be taken in stride rather than dreaded.

So why can't gynecologists and GPs do the same for pelvic exams? Why isn't sedation offered for abuse survivors or others who need it? Is it because of lingering beliefs in the "curse of Eve" where women deserve to suffer pain just for being female? Or that suffering is good for the soul and patients need to suck it up and stop being whiners?

As far as I am concerned, I think that making pelvic exams less of an ordeal is a must, no matter how often women need them.
posted by Rosie M. Banks at 9:12 AM on July 2 [10 favorites]


and the tumor was discovered via abdominal ultrasound

This reminds me of a general question I have: why not do routine abdominal ultrasounds? Is there any sort of risk associated with routine ultrasounds? You know, where video and stills could be taken for cross reference in the future?

In fact, why do we need to visualize the cervix with eyeballs and a speculum when they make scopes small enough to fit into a nasal passage? Again, capable of recording video should one's condition need to be compared over time.
posted by Lyn Never at 9:16 AM on July 2 [4 favorites]


I really like my doctor and I've been with her for years, but I'm getting very tired of her insistence on a yearly pap and (limited) pelvic exam. I had cervical dysplasia in my early 20s, with two laser treatments and paps every four months for two years after, so I've really had more than enough of speculum and cervix scraping. Last time I had an annual physical, I tried to talk to her about the every 3 years recommendation but she wasn't very receptive.

She is very gentle with the pelvic though, so the speculum and the pap smear are the more unpleasant element for me.
posted by Squeak Attack at 9:26 AM on July 2


I'm bringing my 15-yr in to get on birth control and my gynecologist wants to do a Pap smear if she has been sexually active. According to her, she has had sex once, with a condom. She's also had the Gardasil vaccinations. I'm really tempted to have her tell the gyno that she has not been sexually active yet. She's freaked out about the possibility of a pelvic exam/Pap smear/whatever (it's all the same to me) and I understand how she feels. I felt practically traumatized by my first one at age 18.
posted by cherrybounce at 9:35 AM on July 2 [1 favorite]


I'm bringing my 15-yr in to get on birth control and my gynecologist wants to do a Pap smear if she has been sexually active. According to her, she has had sex once, with a condom. She's also had the Gardasil vaccinations.

I think it is super, super awesome that you are having these conversations with your daughter and that she is comfortable talking to you about this (at least comfortable enough to do it, even if it's hard for her).

One of my most painfully awkward memories is telling my mom, at the age of fifteen, that I wanted to go on the pill (I hadn't had sex yet but was thinking about it). Interestingly, she doesn't remember this conversation AT ALL I think because for her it blended into a lot of other conversations about health and bodies and taking your teenage daughter to the gynecologist seemed like a really reasonable thing to her, but even with a really thoughtful and open mother it's HARD to have these conversations and it's really really wonderful that you're creating a space where your daughter can do that. Awesome.
posted by Mrs. Pterodactyl at 9:46 AM on July 2 [3 favorites]


Just to clarify: what happens if you refuse a pelvic exam? Can you not do that in the US system? I've always either been asked or been accepted at saying no for myself and my daughters when I used to accompany them. Is this actually mandatory??
posted by viggorlijah at 10:32 AM on July 2


> In fact, why do we need to visualize the cervix with eyeballs and a speculum when they make scopes small enough to fit into a nasal passage? Again, capable of recording video should one's condition need to be compared over time.

That's a really good question. My guess is cost, but you're so right. I had surgery on my knee through an incision smaller than my pinky nail. And recording means that specialists can be consulted about anything strange-looking without a repeated exam, too.
posted by Westringia F. at 10:34 AM on July 2


what happens if you refuse a pelvic exam?

It never occurred to me to do so, and I've never been asked if I wanted one or not. No one has ever before suggested to me a difference or separateness between a pap smear and a pelvic exam, I always assumed medical fisting was part of the deal.

ha ha ha never agaaaain
posted by elizardbits at 11:13 AM on July 2 [4 favorites]


Speaking of pelvic exams being uncomfortable, I wonder if something I experienced is "normal"... Before getting my first pelvic exam through a free cervical cancer screening program, on the forms I had to fill out before the appointment, there was a question about whether or not I'd ever been sexually assaulted (I forget the exact wording). I understand that was, I hope, to determine whether or not I might need special accommodation or something (though I'm not sure what they would have done differently), but I wonder if that's really necessary? I don't really want to be reminded of that right before I go in. On my latest exam, I haven't had that question posed to me, thankfully, since the last time I was in stirrups was for a rape kit and I was already trying desperately to not to relive that memory.

Has anyone else had this question posed to them before an exam?
posted by mingo_clambake at 11:30 AM on July 2


what happens if you refuse a pelvic exam?

I periodically refuse them, not being a fan of excessively intrusive examinations without symptomatic justification, nor a fan of excessive screening. The only time I was ever forcibly examined was in an adolescent psych unit, and I'm still not convinced that everything that happened there was legal. I think the more common reaction is refusal to prescribe contraception, which has certainly happened to me a few times. But that's something that can happen to you for all kinds of reasons, from being ornery to being perceived by the doctor/NP as slutty, and that's a bigger social problem than the clinical validity of pelvic exams.
posted by bowtiesarecool at 1:20 PM on July 2 [4 favorites]


Has anyone else had this question posed to them before an exam?

never. and i've been treated really weirdly when i brought it up to see if maybe the bedside manner would improve any (it didn't - i stopped bringing it up).
posted by nadawi at 1:48 PM on July 2


I'm not in a position to look it up right now but I suspect that the reason we don't do abdominal ultrasound routinely on asymptomatic nonpregnant women is that it would require your GP to have a clinical ultrasonographer and radiologist on staff.
posted by gingerest at 2:25 PM on July 2 [1 favorite]


Well, with the routine nature of prenatal ultrasounds and transvaginal ultrasounds becoming more common, I don't know why you'd need to retain someone on staff for abdominal ultrasounds for non-pregnant women.
posted by Sara C. at 3:33 PM on July 2


I'm bringing my 15-yr in to get on birth control and my gynecologist wants to do a Pap smear if she has been sexually active. According to her, she has had sex once, with a condom. She's also had the Gardasil vaccinations.

You need to fire your doctor. In the US, pap tests aren't recommended until age 21 or three years after first sex, whichever comes LAST. And pap tests have nothing to do with birth control: the only test required for the pill is blood pressure.
posted by Violet Hour at 3:38 PM on July 2 [4 favorites]


Gingerest, it's definitely not a specialist position for the basic ultrasound scan. The obgyns I've been at here in Singapore and Cambodia have had small portable units on a rolling trolley, with different attachments for transvaginal (no full bladder needed) or abdominal (full bladder before appointment). For the next level up where you're diagnosing complicated birth defects, you go to a specialist where the ultrasound machine is bigger, the screen is much clearer and there's a specialist technician and doctor, but that's for the 'full' scan at 20 weeks pregnancy or for pre-surgery scans, not for the initial routine diagnostic scan.

Is it not routine to have an ultrasound machine at the ob-gyns? It's such a basic thing that I assumed it was there but not used as an alternative for efficiency - a pelvic exam is probably faster. Or maybe cost?
posted by viggorlijah at 5:33 PM on July 2


I'm not sure that a routine yearly transvaginal ultrasound (or, as I like to call it, the Sonic Screwdriver) would be any less anxiety provoking, and I suspect -- although I haven't looked at the numbers -- that the specificity of ultrasound (TV or abdominal) is low enough that it would be of no use in an asymptomatic, low-risk population.
posted by Westringia F. at 5:37 PM on July 2 [1 favorite]


Actually, I'm going to run the numbers. Here: the incidence of ovarian cancer in the US is 12.3 per 100,000 women per year. The specificity (true negative rate) and sensitivity (true positive rate) of ultrasound screening are 98.2% and 84.9%, respectively.

Approximately 63 million well-woman screening exams are conducted each year, which for simplicity I'll round down to 50M. Of those 50M women being screened, 6150 (50M*12.3/100,000) will have truly developed ovarian cancer.

Suppose now that we do the routine screening by ultrasound. 5498 of the 6150 women with cancer (0.894*6150) will have their cases detected by the ultrasound, missing 652 of them. However, along with the 5498 true positives, we would also get 899,889 false positives [(1-0.982)*(50M-6150)] -- nearly a million. In total, switching over to ultrasound screening would give 905,387 positives, of which only 0.6% (5498/905387=0.006) were correct. (This, BTW, is the positive predictive value, which tells you how much you should believe the result you get.)

That is: screening everyone with an ultrasound as part of a well-woman exam is completely useless, because even if you get a positive result, there's a 99.4% chance that she's just fine. You wouldn't be able to trust the positive results, and would scare nearly a million women per year in the offing.

[Note, however, that screening in a high risk group (or in women with symptoms) is useful. The reason the numbers are awful here is because 99.987% of healthy women will NOT get ovarian cancer within the year; you're testing everyone without reason. If there is other reason to believe that the woman's risk of having gotten cancer since her last exam is much higher than the baseline of 12.3/100,000, then the positive predictive value is much stronger. I'll leave it as an exercise for the reader to determine how high her (prior) risk has to be in order for the PPV to be 0.5 -- ie, a coin toss' chance that a positive result from the ultrasound is correct.]
posted by Westringia F. at 5:39 PM on July 2 [5 favorites]


So if a pelvic exam is even less informative than an ultrasound....
posted by viggorlijah at 5:52 PM on July 2


Sara C.: "Well, with the routine nature of prenatal ultrasounds and transvaginal ultrasounds becoming more common, I don't know why you'd need to retain someone on staff for abdominal ultrasounds for non-pregnant women."

Clinical ultrasounds aren't usually interpreted by GPs or OB/GYNs even in those circumstances. So there would have to be either a tech and radiologist on staff (which is what happens with OB/GYN practices that read their own ultrasounds) or patients would need to be sent out (which is what usually happens in GP/family med settings where ultrasounds are needed_. You're right, there's plenty of precedent for that in routine pregnancy treatment. But Westringia F. is right on it - the clinical case for annual routine abdominal ultrasound screening of asymptomatic women for ovarian cancer doesn't pencil out.

And, no, pelvic exams don't pencil out, either. But that's the whole point of the ACP guideline.
posted by gingerest at 6:45 PM on July 2


The insurance companies are going to be happy to see another diagnostic test bite the dust - and how nice it will be for women everywhere to never have another pelvic exam - Yay! They've questioned the usefulness of mammograms, colonoscopies and prostate exams and many insurance companies are backing away from diagnostic tests as completely as they can. My daughter's insurance pays for three, and three only, diagnostic tests a year! That includes diagnostics that are directly related to ongoing problems - not just screening tests. So recently she's had a blood panel, urinalysis and CT for deep pelvic pain - that's all the insurance would pay for - she's on the hook for the transvaginal ultrasound that found adenomyosis growing into her uterine wall and endometriosis outside the uterus. No more tests for a year.

I have an "adopted" daughter who is under 50 who hated the idea of a colonoscopy and her doctor thought it probably unnecessary; she's now had surgery with a colostomy, eight months of chemotherapy, surgery again to close the colostomy, at which time they found cancer in her ovaries, one kidney and a lung. She's now in her second round of chemo - and pretty well devastated.

My neighbor is an old man who avoided prostate exams. He's in hospice care now with prostate cancer and mets to the brain.

A very dear friend for many years passed away a year and a half ago from breast cancer that metastasized to the bone and beyond. It was found on a mammogram. I hate mammograms because they hurt and I have two other extensive health conditions that will take me out anyway, so I opt out of the mamms, but I definitely understand that if there is a breast cancer it's not likely to just start beeping or something so I know it's there.

Some cancers are nearly impossible to catch early on and have no even-halfway-decent tests that are reliable and many tests of all kinds freely result in false positives, but that doesn't mean they should be eliminated (even though, as I said, the insurance industry would be happy if that were the case).

As for the physical and mental discomfort of a pelvic and Pap smear, what?? I assume these women haven't had a baby yet, right? If you're shy about your genitalia now, you'll get over it in a hurry when you have a child, but even if you don't have children, it won't hurt you to just grow up and take care of that part of your anatomy like you do the rest of it. Seriously - it'll all be over in a half hour and it won't hurt nearly as much as a root canal.

Please consider who's going to really benefit here - the answer is those who pay the bills. Yes, some false positives won't take place, but neither will some not-false positives - the ones that really matter. If there's discomfort or embarrassment in some of the tests, and there is indeed, just deal with it and get it done anyway. It may mean that you get to watch your kids or grandkids grow up and they don't want to lose you for fear of an "icky" prostate exam/pelvic/mammogram/colonoscopy.

Most important, don't let the insurance companies dictate what medical procedures your doctor can use to diagnose - or screen - your body's health. That's what your physician is for.
posted by aryma at 8:10 PM on July 2 [1 favorite]


Mammograms, colonoscopies, prostate exams all require extra equipment and extra staff - pathologists, radiologists, surgeons - to collect samples and analyse the results. I would imagine they are significantly more costly than manual pelvic exams.
posted by gaspode at 8:51 PM on July 2 [1 favorite]


If you're shy about your genitalia now, you'll get over it in a hurry when you have a child

Not all women have children, and framing "well get used to it, childbirth hurts" is kind of crazy.

Nobody ridicules men who don't want an annual rectal exam by saying, "get used to it, being hit by a car hurts."

I mean, what do pelvic exams even have to do with childbirth?

And I say all of the above as someone who isn't terribly troubled by the occasional pelvic exam.
posted by Sara C. at 8:57 PM on July 2 [12 favorites]



Most important, don't let the insurance companies dictate what medical procedures your doctor can use to diagnose - or screen - your body's health. That's what your physician is for.


Nope, that's what I am for. I'm perfectly capable of weighing pros and cons: it's called informed consent. The only person who gets to decide what proceedures I undergo is me.
posted by Violet Hour at 9:03 PM on July 2 [6 favorites]


First of all, the American College of Physicians is a professional organization of doctors who specialize in internal medicine. I'm not sure why anyone would assume that they speak for insurance companies, and it seems to me that doctors would stand to benefit more from keeping the recommendation to do annual exams than from scrapping it. They're the people who get paid for procedures, not the people who do the paying.

Second of all, insurance companies benefit from effective preventative care, because it saves them from paying for more expensive care down the line. Your insurance company wants you to get a Pap smear and a colonoscopy, because precancerous conditions are a lot cheaper to treat than cancer.

Third of all, I want to make medical decisions based on evidence, not on overwrought anecdotes. I'm not going to pretend that I'm fully able to do that: nobody is completely objective about their own health, and sometimes the evidence is unclear or confusing. But I try really hard. If there's really no evidence that pelvic exams do any good, then I'm not going to get one, no matter how many people tell me that their friend's cousin's dog-walker's aunt's life was saved by a pelvic exam.
posted by ArbitraryAndCapricious at 9:18 PM on July 2 [6 favorites]


The insurance companies are going to be happy to see another diagnostic test bite the dust

There is no "diagnostic test biting the dust" here. This is about routine screening of asymptomatic, nonpregnant adult women, and the recommendation is a practice guideline from physicians to other physicians based on systematic evaluation of the evidence that pelvic exams provide more benefit than they do harm.
posted by gingerest at 9:47 PM on July 2 [1 favorite]


aryma, did you even bother to read the math* I posted above? The false positives swamp the true ones to the point that the result is meaningless in the general population. The nice thing about math is that you can check it yourself and know if $TheMan [insurance/gov't/&c] is lying. Read the damn math.

> As for the physical and mental discomfort of a pelvic and Pap smear, what?? ... it won't hurt you to just grow up and take care of that part of your anatomy like you do the rest of it.

Wow, that's remarkably offensive. I don't know why I thought you'd bother reading my math when clearly you're too good to read the dozens of comments in this thread by women explaining the "what??" of how it does hurt, often in soul-bearing detail.

It won't hurt you to just grow up, read the thread before commenting, and take care to keep your insensitive condescension in whatever part of your anatomy it originated.

_____
* Those were ultrasound figures, but the numbers are as bad or worse for pelvic exams [1,2,3,4,5], which is precisely why the recommendation to decrease them was made.
posted by Westringia F. at 9:48 PM on July 2 [9 favorites]


As for the physical and mental discomfort of a pelvic and Pap smear, what?? I assume these women haven't had a baby yet, right? If you're shy about your genitalia now, you'll get over it in a hurry when you have a child, but even if you don't have children, it won't hurt you to just grow up and take care of that part of your anatomy like you do the rest of it. Seriously - it'll all be over in a half hour and it won't hurt nearly as much as a root canal.

If you read through this thread, several people have mentioned that the "discomfort" they feel during/before/after pelvic exams is intimately tied in with their experiences of sexual assault. Given the depressing statistics about how pervasive those experiences are, you could maybe consider being less flippant? Please?
posted by mingo_clambake at 9:53 PM on July 2 [8 favorites]


People should be sure to read Westringia's comment on sensitivity, specificity, and positive predictive value.

This is why public health gets involved in medicine: because, on a population scale, "more of a good thing" doesn't mean "better."

For certain tests to be effective, they need to be deployed under precise conditions. when done for everybody, they just provide noise that wastes time and money and sends people down a false positive rabbit hole.

That's bad medicine.
posted by entropone at 5:06 AM on July 3


I have an "adopted" daughter who is under 50 who hated the idea of a colonoscopy and her doctor thought it probably unnecessary; she's now had surgery with a colostomy,...

A colonoscopy is not a healthy thing to undergo without reason. It requires flushing out your insides and general anesthesia along with insertion of a foreign tool into the body. There's also a risk of perforating the colon.
posted by MisantropicPainforest at 6:05 AM on July 3 [1 favorite]


I have an "adopted" daughter who is under 50 who hated the idea of a colonoscopy and her doctor thought it probably unnecessary

For the average person under 50, colonoscopies are NOT necessary. 50 is the recommended age to start colon cancer screening. Colonoscopies are recommended for under-50s if there is a history of colon cancer in the family or the person has certain illnesses or hereditary syndromes that put them at risk.

Aryma's daughter was unlucky, certainly, but her doctor was not negligent in telling her she didn't need a routine colonoscopy.
posted by Rosie M. Banks at 7:06 AM on July 3 [1 favorite]


I really wish the question of insurance coverage didn't get tied into whether tests are medically necessary at a population level. I know it has to, in the US, given our health insurance situation. I just wish it didn't have to.

My insurance covers zero diagnostic tests per year until I hit my deductible, at which point everything is covered. Routine tests are covered as required by medical guidelines, unless they show something, at which point they are retroactively re-coded as "diagnostic" and I get to pay for them unless I've hit my deductible. As far as I know this is fairly standard -- is that not the case? Are there ACA-compliant plans in the US that don't cover the costs of diagnostic testing once the patient is over their deductible or max OOP? (I mean, it sucks paying for things until I hit the deductible, and I'd much rather be in a system that worked differently. But this is the system we have. At least the ACA has cut down on some of the really crappy plans, like the "lifetime cap" crap.)

For the average person under 50, colonoscopies are NOT necessary. 50 is the recommended age to start colon cancer screening.

Unless you have a family history of colon cancer or some other cancers, or unless you're adopted and don't know your birth family's medical history, in which case doctors may recommend starting at 40 to be safe (and I think that's now under discussion?). We don't know this woman's history, and we don't have enough information to determine whether the doctor may have been negligent under some standards of care.
posted by pie ninja at 8:28 AM on July 3


I certainly weigh the fact that insurance companies hate routine testing (well, they hate paying for it) into my consideration of which tests are appropriate for me. I also weigh in the fact that lots of routine testing is 1. a profit center for my medical practice and 2. covering the ass of my doctor for malpractice suits even if I don't need that test.

Financial incentives run both ways for routine testing.
posted by immlass at 8:41 AM on July 3 [2 favorites]


I really wish the question of insurance coverage didn't get tied into whether tests are medically necessary at a population level. I know it has to, in the US, given our health insurance situation. I just wish it didn't have to.

No, it's more complicated than that. It's not about health insurers trying to save money - it's about keeping the tests useful.

Again, I urge readers to read Westringia's comment about sensitivity, specificity, and positive predictive value. It gets at some of the complexity of screening and diagnostic tests. More of a good thing isn't better, which is why (as Rosie M. Bankspoints out) there are guidelines & recommendations for screening tests (over 50 for colonoscopy; or under 50 only if there's a history of colorectal cancer in the family, etc). These aim to narrow down the population being screened, in order to improve the performance of the screening test.

False positives are bad. Low positive predictive values of tests are bad. Changing recommendations based on research/evidence/science is about improving the precision of medical care, on a population level.
posted by entropone at 9:43 AM on July 3 [3 favorites]


So why can't gynecologists and GPs do the same for pelvic exams? Why isn't sedation offered for abuse survivors or others who need it? Is it because of lingering beliefs in the "curse of Eve" where women deserve to suffer pain just for being female? Or that suffering is good for the soul and patients need to suck it up and stop being whiners?

I'm guessing that a lot of women wouldn't want to be sedated for a pelvic exam because they don't want to lose control of their bodies during such an intimate procedure. Although I don't know how common it is, it's not unheard of for doctors to take sexual advantage of their patients - isn't that why a nurse is also required to be present? But there's a lot that could be done to make them easier.

what happens if you refuse a pelvic exam?

I've known women who were told they'd have to find a different doctor after repeatedly refusing or avoiding pelvic exams. Granted, it's not the Spanish inquisition or anything, but finding a new doctor isn't exactly easy, especially with the insurance system in the U.S.

I'm not sure that a routine yearly transvaginal ultrasound (or, as I like to call it, the Sonic Screwdriver)

I've never been able to look at a stick blender the same way since my first transvaginal ultrasound.
posted by The Underpants Monster at 9:47 AM on July 3 [1 favorite]


I don't think I know anyone who would opt for actual sedation during the procedure but I know a lot of women whose lives would be much easier if they could get a single benzo beforehand.
posted by elizardbits at 9:51 AM on July 3 [2 favorites]


No, it's more complicated than that. It's not about health insurers trying to save money - it's about keeping the tests useful.

Oh, man, no, I said that badly. I agree with you. It's more that I wish insurance coverage wasn't part of this discussion at all. Every time something like this comes out, the discussion turns into "This is just health insurers trying to deny coverage!"

But as you said, that's not what it's about. It's about trying to make the tests as useful as they can be, by applying them to the right population.
posted by pie ninja at 10:52 AM on July 3 [3 favorites]


For what it's worth, my gynocologist prescibes me benzos before my annual exam. I live in a place with lots of care options so I was able to shop around for someone who took my insurance and understood my medical anxiety.

He also meets with me, fully clothed and in his office, before the exam. This is incredibly useful and makes me feel more like a person getting health care (emphasis on care). I wish all women had this option. When I used to go to planned parenthood it was really a demoralizing experience - I always had to wait, often for hours, clad in nothing but a paper sheet, in a cold room to see a brusque and busy doctor. Being able to go to a private practice gyn is a whole other ball game.
posted by sockermom at 11:14 AM on July 3 [1 favorite]


Just for the record, my "adopted" daughter went to the doctor complaining of bloating, feeling too full too fast, cramping and a sort-of "pulling" feeling in her left abdomen which would double her over sometimes, and an on-again off-again battle with diarrhea. Her stool sample was only very mildly positive, which the doctor felt was probably due to hemorrhoids or contamination from menstrual blood. She was given a colonoscopy when the stool began to show frank blood, which was a good six months after her first visit and she'd been seen one other time during that six months for the same thing.

I think a mild sedative for those who are traumatized by the procedure is an excellent idea; they give it (not general anesthesia) for colonoscopies and for an MRI if the claustrophobia is too stressful.

I would be dumbfounded to think that any GYN in today's world would do an internal exam without a nurse in the room - all it really takes is an accusation for the physician's career to dissolve. For that matter, there's a sign posted in my Pulmonologist's office offering a "chaperone" in the room if you'd like.

I stand by my uneasiness at the idea of insurance companies directing physicians in anything to do with their practice; my care should be between my physician and myself.

The subject of whether or not pelvic exams are necessary is actively being debated between different medical organizations (mostly by specialty) and that will continue, which is a good thing because it's the only way good medicine will prevail.
posted by aryma at 1:06 PM on July 3


Has anyone else had this question posed to them before an exam?

Yes, and I had it posed just yesterday before my intake for pelvic floor physical therapy.

I find it comforting that they ask, so that they can be aware of whatever issues someone might have. I think the positive done by asking (the patient knows they are considering it and are aware that it could be an issue) outweighs the possibility of the mere mention being triggering, if you're going to be having a pelvic exam either way.
posted by fiercecupcake at 1:48 PM on July 3 [1 favorite]


Just for the record, my "adopted" daughter went to the doctor complaining of bloating, feeling too full too fast, cramping and a sort-of "pulling" feeling in her left abdomen which would double her over sometimes, and an on-again off-again battle with diarrhea.

A diagnostic test given when a patient is presenting with symptoms is a totally different story from a routine exam asymptomatic women must undergo annually just because That's The Way It's Always Been Done.
posted by Sara C. at 1:50 PM on July 3 [8 favorites]


I stand by my uneasiness at the idea of insurance companies directing physicians in anything to do with their practice; my care should be between my physician and myself.


That is not what is happening here. Insurance companies have nothing to do with this. This is about evidence-based practice.

I am very sorry that people you care about have had inadequate medical care, including insufficient diagnostic work-up for symptoms. Many of us share that experience, for reasons of insurance, negligence, or poor accessibility of care. But this practice guideline has nothing to do with those experiences - it's about the decision to stop universally administering an invasive exam to a specific population because it doesn't detect anything in that population.
posted by gingerest at 8:19 PM on July 3 [8 favorites]


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