Patient Population Under Consideration
This recommendation applies to asymptomatic women 18 years and older
who are not at increased risk for any specific gynecologic conditions,
such as ovarian or cervical cancer. It does not apply to pregnant women
or adolescents.
Suggestions for Practice Regarding the I Statement
Potential Preventable Burden
Numerous gynecologic conditions may be detected during a screening
pelvic examination. These include malignant diseases, such as ovarian,
uterine, vaginal, and cervical cancer; infectious diseases, such as
bacterial vaginosis, candidiasis, genital warts, genital herpes,
trichomoniasis, and pelvic inflammatory disease; and other benign
conditions, such as cervical polyps, endometriosis, ovarian cysts,
dysfunction of the pelvic wall and floor, and uterine fibroids.
The accuracy of detecting and the benefit of treating some of these
conditions early, while women are asymptomatic, is unknown. No studies
evaluated the effectiveness of early diagnosis and treatment of
screen-detected, asymptomatic gynecologic conditions compared with the
diagnosis and treatment of symptomatic gynecologic conditions.4
It is also unknown whether performing screening pelvic examinations
more frequently than every 3 to 5 years (the recommended screening
interval for cervical cancer) is beneficial. Although it is common
practice to perform a pelvic examination as part of an annual physical
examination, the benefit of performing screening pelvic examinations at
this interval is unclear. The benefit of using pelvic examination alone
to screen for gynecologic conditions other than cervical cancer,
gonorrhea, and chlamydia is also unknown.
Potential Harms
The USPSTF found limited evidence on the harms of screening with
pelvic examination. Harms reported in studies included false-positive
and false-negative results. Available evidence reports false-positive
rates for ovarian cancer of 1.2% to 8.6% and false-negative rates of 0%
to 100%.4
Pelvic examination screening also could result in unnecessary
diagnostic workup and treatment. In particular, there is a concern for
potential invasive diagnostic procedures and treatment of ovarian cancer
(such as surgery) that could result from evaluating abnormal findings
on pelvic examination. In the reviewed studies, approximately 5% to 36%
of women who had abnormal pelvic examination findings went on to have
surgery.4
The potential association between urinary tract infections and pelvic
examinations was explored in a single study with inconclusive results.6
Additional theoretical harms of pelvic examination include
psychological harms (anxiety), pain and discomfort from the examination,
and the potential for these harms to serve as a barrier for women to
receive medical care.
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 decisionmaking with the patient to
determine whether to perform a pelvic examination.
Current Practice
According to the National Ambulatory Medical Care Survey, 44.2 million pelvic examinations were performed in 2012.1
In a 2010–2011 nationally representative survey of obstetricians and
gynecologists, almost all surveyed clinicians indicated that they would
perform a bimanual examination on asymptomatic patients during routine
visits.7
According to another survey performed in 2009, 78% of surveyed
clinicians (including obstetricians/gynecologists, family or general
practitioners, and internists) believed that pelvic examination is
useful for screening for gynecologic cancer in asymptomatic women;
approximately 50% to 60% reported believing that pelvic examination is
useful for cervical cancer screening, 49% to 70% for ovarian cancer (70%
of obstetrician/gynecologists vs 49% to 50% of internists and family
practitioners), 39% to 45% for uterine cancer, 57% to 62% for vaginal
cancer, and 53% to 62% for vulvar cancer (estimates are based on graphic
display of data, exact numbers were not provided).8
Nearly all surveyed clinicians (97%) believed that the pelvic
examination included bimanual examination, while most (69%) believed
that the pelvic examination included rectovaginal examination.8
Research Needs and Gaps
The USPSTF recognizes that research on the effectiveness of the
screening pelvic examination is difficult, given that multiple
conditions could potentially be detected with this single preventive
service. However, in reviewing the currently available evidence on the
benefits and harms of performing screening pelvic examinations in
asymptomatic adult women, the USPSTF identified the following critical
evidence gaps. Studies evaluating the accuracy and effectiveness of
screening pelvic examination to detect conditions other than ovarian
cancer, bacterial vaginosis, genital herpes, and trichomoniasis are
lacking. Studies reporting on the harms of screening with pelvic
examination (including quantified psychological harms) in asymptomatic
women in primary care are also lacking.
Studies reporting the effects of performing routine screening pelvic
examinations on health outcomes such as all-cause mortality,
disease-specific morbidity and mortality, quality of life, and
psychological benefits and harms could help fill the gaps in the
existing evidence and inform future USPSTF recommendations. Studies
evaluating and quantifying harms are needed, as well as studies
evaluating the potential effectiveness of risk assessment tools to
determine which women might benefit from a pelvic examination. Research
is needed to clarify which indications primary care clinicians are
currently using the screening pelvic examination for in asymptomatic
patients and which components of the pelvic examination are performed
most frequently. Studies exploring women’s attitudes toward pelvic
examinations, the outcomes women value from these examinations, and how
pelvic examinations affect women’s decisions to seek and obtain care are
also needed to clarify the potential benefits and harms of providing
this preventive service.
Screening Tests
For the purposes of this recommendation, the term "pelvic
examination" includes any of the following components, alone or in
combination: assessment of the external genitalia, internal speculum
examination, bimanual palpation, and rectovaginal examination.
Useful Resources
Screening for cervical cancer, gonorrhea, and chlamydia are not
included in this recommendation statement on screening pelvic
examinations because they are already addressed in separate USPSTF
recommendations.2, 3
Screening for ovarian cancer with preventive services other than pelvic
examination is addressed in the USPSTF's recommendation on screening
for ovarian cancer;9 the USPSTF also has recommendations on counseling to prevent sexually transmitted infections.10
The Women’s Preventive Services Guidelines, supported by the Health
Resources & Services Administration, is another resource.11