I am so confused, when do I need a pelvic exam???

I am so confused, when do I need a pelvic exam???

There is so much confusion and misinformation when it comes to pelvic exams: what they entail, what they can and cannot diagnose, and how often they are necessary. 

When I was in residency (before computers or Snapchat or memes--yes, I am old), we were encouraged to do A LOT of pelvic exams. I always felt sorry for the unfortunate woman who would show up at a teaching hospital with pelvic pain. She would first get a pelvic exam by a medical student, then an intern, then a chief resident and if something seemed really wrong, an attending physician. If she didn't have pelvic pain when she walked in, she sure would when she left. I am cringing as I write this.

We also did pelvic exams if a woman needed a refill of her birth control, or a routine STD check. Why??? There are important reasons that this is no longer necessary. Every woman should know these reasons.

Pelvic exams were routine because it was all we had . . . 20+ years ago. Western medicine is a like a large ship that is only able to turn very, very slowly. And a 180 degree turn takes decades. Pelvic ultrasounds are widely available and much more accurate, with some exceptions, than a hands-on pelvic exam ("bimanual" in doctor speak). If a woman has pelvic pain or abnormal bleeding, I usually will do a pelvic exam but I will also order an ultrasound. If she is someone who is obese or finds pelvic exams traumatic, I will sometimes skip the exam and go right to the ultrasound.

The American College of OB-GYN (ACOG) has finally come around to recognizing this. Their guidelines specifically state: "pelvic examinations should be performed when indicated by medical history or symptoms. " (Committee Opinion #754, October 2018, if you don't believe me.) This means pelvic exams do not need to be done every year.

We can now do most STD screening with a simple urine test. If a woman needs routine screening because of a new partner or peace of mind, she does not need a pelvic exam. Now if she is having unusual discharge or itching or pelvic pain, then she probably does need an exam.

Pap smears and pelvic exams are NOT the same thing. Again, paps and pelvics are not the same. I want to type this twenty times, but I think you get my point. A pap smear is just a small part of the pelvic exam that screens for cervical cancer. This is now done every 3-5 years beginning at age 21, assuming the pap is normal.

Pelvic exams do not screen for ovarian cancer. As of right now, there is no screening test for ovarian cancer and most early ovarian cancer cannot be detected by a pelvic exam. Unless a woman is very thin or has a very large ovary, her provider likely is not able to feel her ovaries. Confession: When I say "everything feels normal" after a pelvic exam, it means that I do not feel any unusual masses. It does not mean I can feel the size and shape of your ovaries.

Most large pelvic masses are not cancer. Most of the time, they are not even clinically significant. Mind you, I have done tens of thousands of pelvic exams and have detected some masses that need to be surgically removed. However, most of the time the woman is having symptoms that necessitate removal. These masses include large benign fibroids and ovarian cysts. As an aside, I have removed ovaries and/or fibroids as large as basketballs. These were painful but benign.

Teen girls do not need pelvic exams unless they are having unusual symptoms. This would include frequent irregular bleeding, new discharge or new pelvic pain. It is normal for a teen to have painful or heavy periods, as long as they are regular and predictable. If a teen is sexually-active, she needs STD testing but again, this does not have to involve a pelvic exam.

Unwarranted pelvic exams can be traumatic. This is a problem because when that same woman is having symptoms three years later, she probably will avoid seeing a provider because of her past experience. This is especially true for younger women.

Knowledge is power. Knowledge can help you advocate for yourself and can help you become your best self.

Dr. Cynthia McNally, MD

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