A recent recommendation published by The American College of Physicians, the organization that represents internists, stated that non-pregnant women who do not have specific complaints don’t need to have a gynecologic exam. To be clear (since “pelvic exam” means different things to different people), what they are recommending is that if you have a Pap test, you do not need a bimanual exam to evaluate pelvic organs like your uterus or ovaries. If you do not need a Pap test, you don’t need to get undressed from the waist down. Before you scream woo-hoo and start the celebration, I need to point out a few a few reasons to think twice before passing on your exam.
1. Let’s start with the no complaint part.
Studies have shown that the majority of women who have conditions such as urinary incontinence, fecal incontinence, vaginal odor, vaginal dryness, unusual discharge and vulvar discomfort do not mention it to their doctor, either out of embarrassment, or thinking that involuntary loss of urine and painful sex are a “normal” part of aging. Studies also show that the majority of doctors do not ask if these symptoms exist and more often than not, these conditions go untreated. One of the key messages here is speak up! Don’t wait for your doctor to ask, because they may never do so.
2. Many conditions don’t have symptoms.
There are a myriad of pelvic conditions that do not have symptoms, but early diagnosis can sometimes make a big difference when it comes to averting serious illness down the road. Just a few months ago I saw a 55-year-old woman who had not seen a gynecologist for years. Since she had “no complaints” her doctor did not put a speculum in or look in her vagina at her annual exam and she was told the pelvic exam was unnecessary because she’d had a hysterectomy. Eventually, she did have a complaint, a bloody vaginal discharge. She came to me and a 15 second speculum exam detected what turned out to be a Stage 4 vaginal cancer. These things don’t turn up overnight and a vaginal exam long before it became symptomatic would have detected her problem when it was early and treatable. Just because your uterus is gone, or out of business, does not mean that your vulva or vagina can’t develop a problem.
The obvious question is, what’s the harm in performing an annual speculum and bimanual pelvic exam? According to The American College of Physicians:
Pelvic exams can be embarrassing.
While this may be the case, this isn’t a good reason not to get an exam. Rectal and testicular exams are also embarrassing. Should those be omitted as well? This propagates and validates that many women’s health concerns are taboo topics. You should never think to yourself, “Shh! Don’t talk about your vaginal odor. Don’t talk about your sexual concerns. Don’t talk about your incontinence. Not even to your doctor.” If every other body part is examined but the genitals, it sends a clear message that the pelvis, vagina and vulva are not part of the regular comprehensive physical. The pelvic exam should be normalized, not marginalized.
The article reports that up to 60 percent of women said the exam was painful. One has to wonder why the majority of the patients in the study experienced pain. Was the person inserting the speculum inexperienced? Did he or she use the wrong size speculum? (One size does not fit all!) Or perhaps some of the patients suffered from vaginal dryness, a condition that should be discussed with your doctor. A pelvic exam should never be painful, and if it is, it may indicate a problem.
It takes time.
Yes it does. At least one minute. So does listening to a heart, or doing a breast exam. I am guessing my patient with vaginal cancer would have been glad to put up with one minute of embarrassment instead of undergoing cancer treatments and fighting for her life.
The American Congress of Obstetricians and Gynecologists (ACOG) continue to recommend an annual pelvic exam, even in a non-Pap test year because they still believe the benefits of a yearly exam outweigh the risks. The real message is, there is value in an annual exam, but it depends on who does it. So take your pelvis to a doctor (or advanced practice nurse) and get it checked out on a regular basis.