Periodic Screening Pelvic Examination

Abstract

IMPORTANCE Recent changes in the periodicity of cervical cancer screening have led to questions about the role of screening pelvic examinations among asymptomatic women.OBJECTIVE To systematically review literature on health benefits, accuracy, and harms of the screening pelvic examination for gynecologic conditions for the US Preventive Services Task Force (USPSTF).DATA SOURCES MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through January 13, 2016, with surveillance through August 3, 2016.STUDY SELECTION Two reviewers independently screened abstracts and studies. The search yielded 8678 unique citations; 316 full-text articles were reviewed, and 9 studies including 27 630 patients met inclusion criteria. DATA EXTRACTION AND SYNTHESISTwo reviewers rated study quality using USPSTF criteria.MAIN OUTCOMES AND MEASURES Morbidity; mortality; diagnostic accuracy for any gynecologic cancer or condition except cervical cancer, gonorrhea, and chlamydia, which are covered by other USPSTF screening recommendations; harms (false-positive rates, false-negative rates, surgery rates). RESULTSNo trials examined the effectiveness of the pelvic examination in reducing all-cause mortality, reducing cancer-and disease-specific morbidity and mortality, or improving quality of life. Eight studies reported accuracy for the screening pelvic examination: ovarian cancer (4 studies; n = 26 432), bacterial vaginosis (2 studies; n = 930), trichomoniasis (1 study; n = 779), and genital herpes (1 study; n = 779). In the 4 ovarian cancer screening studies, low prevalence of ovarian cancer consistently resulted in low positive predictive values (PPVs) and false-positive rates, with a lack of precision in accuracy estimates (sensitivity range, 0%-100%; specificity range, 91%-99%; PPV range, 0%-3.6%; negative predictive value [NPV] range, Ն99%). Each diagnostic accuracy study for bacterial vaginosis, trichomoniasis, and genital herpes was performed in a high-prevalence population with substantial proportions of symptomatic patients and reported accuracy characteristics for individual physical examination findings (bacterial vaginosis, homogeneous discharge:

Women’s beliefs about the purpose and value of routine pelvic examinations

“…Potential harms include false positives leading to diagnostic workups that could include surgery (in 5% to 36% of the 1 to 8% of women with positive screening tests) (16). Their draft recommendation stated that evidence was insufficient to assess the balance of benefits and harms, thus they could not recommend for or against performing screening pelvic examinations.…”

“…In 2016, a systematic review commissioned by the U.S. Preventive Services Task Force (USPSTF) was published that found inadequate evidence concerning the benefits and harms of screening pelvic examinations. Potential harms include false positives leading to diagnostic workups that could include surgery (in 5% to 36% of the 1 to 8% of women with positive screening tests) (16). Their draft recommendation stated that evidence was insufficient to assess the balance of benefits and harms, thus they could not recommend for or against performing screening pelvic examinations.…”

Major clinical research advances in gynecologic cancer in 2017

“…In 2017, the US Preventive Services Task Force (USPSTF) released a statement about the use of pelvic exams in primary care, “the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, non-pregnant adult women” [ 44 ] after a systematic review of available clinical evidence [ 45 ]. In this review, there was no trials examined the effectiveness of the pelvic examination in reducing all-cause mortality and reducing cancer.…”

Effect of professional society recommendations on women’s desire for a routine pelvic examination

“…12 A recommendation by the US Preventive Services Task Force (USPSTF) that followed the review concluded that current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations. 13 The USPSTF believes that statements of insufficient evidence should prompt clinicians to explain to patients the uncertainty about the balance of benefits and harms if the service is offered.…”

“…A systematic review commissioned by the Agency for Healthcare Research and Quality reiterated a lack of evidence of benefit and better characterized harms of screening pelvic examinations, at least in the context of ovarian palpation; abnormal results can be expected in 1.2–8.7% of those screened, leading to surgical exploration in up to 36% of those with positive testing. 12 A recommendation by the US Preventive Services Task Force (USPSTF) that followed the review concluded that current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations. 13 The USPSTF believes that statements of insufficient evidence should prompt clinicians to explain to patients the uncertainty about the balance of benefits and harms if the service is offered.…”