"Put your feet in the stirrups and scootch your butt all the way down. Further down. Little further. Now, try to relax." These are the instructions that usually accompany the routine, often dreaded, pelvic exam that is de rigueur for most gynecological checkups.
Some women are resigned to this exam, others find it embarrassing and unpleasant, and still others may detest it so much they avoid seeking gynecological care in order to skip it -- but what if it wasn't always necessary?
What if women could safely go for two or three years, granted they were healthy and without symptoms of disease, without the hassle?
That is precisely what a commentary published in the January edition of the Journal of Women's Health is suggesting: In healthy, asymptomatic women, a pelvic exam doesn't have to be done yearly, and in women under 21, perhaps not at all. And many gynecologists feel that this assertion has been a long time coming.
Authors of the commentary argue that many of the reasons pelvic exams are employed today are unnecessary and could be replaced by less invasive techniques. The evidence suggests that less frequent pelvic examinations have no detrimental effect on health outcomes in everything from testing for STDS to prescribing hormonal contraceptives to screening for gynecological cancers.
The authors' arguments "are completely valid," says Dr. Diane Harper, director of the Gynecologic Cancer Prevention Research Group at the University of Missouri-Kansas City. "There are so many other health needs, including behavioral medicine, depression, coping skills, domestic violence, etc., that need to be addressed in the time that we used to do pelvic exams."
The American Congress of Obstetricians and Gynecologists is taking this issue to heart.
"It's something that's on their plate for discussion to have possibly new recommendations for the annual examinations in the near future," says ACOG representative Dr. Jessica Shepherd, a Louisville, Ky. based gynecologist. "The reason this is being addressed is that when we look at pelvic exams historically, they have just not been linked to an increase in diagnosis of things like ovarian cancer."
The commentary lays out all the reasons a pelvic exam might be employed in women who otherwise show no symptoms of gynecological issues and then, citing studies and industry guidelines, explains why most of these situations actually do not require such an exam.
A pelvic exam is usually done in order to take a Pap smear, a test that samples cells on the cervix to check for signs of cervical cancer, as part of the examination before prescribing birth control pills or the ring, and to check for signs of uterine or ovarian cancer. This last test is done with a bimanual examination -- two fingers are inserted into the vagina while the other hand presses on the abdomen in order to feel for abnormalities, cysts or fibroids.
In most of these situations, however, a pelvic exam is either irrelevant, ineffective, or needed less frequently, the study authors say.
"Pelvic examination findings do not affect the decision to prescribe or withhold systemic hormonal contraception; a pelvic examination is not needed to initiate these contraceptives. Clinical trial data ... show [that bimanual exams] do not lead to earlier detection of ovarian cancer," the authors write. "No evidence identifies benefits of a pelvic examination in the early diagnosis of other conditions in the asymptomatic."
What's more, while pap smears remain an integral part of early detection of cervical cancer in women, recent changes in the ACOG guidelines now only recommend that they be given every two years to women in their 20s and every three years to women 30 and older, providing that the woman has no previous history of abnormal pap smears and no symptoms.
"These arguments are all facts, based on recommendations as well as studies that have been done," Shepherd says.
So why do most women continue to receive pelvic exams and pap smears annually? Gynecologists say that much of it just has to do with inertia: many of the guidelines quoted above are relatively new and it will take time for both women and their doctors to adjust to the idea that these tests are not needed every year.
For decades that was the standard of practice and thus many women have become used to this being a necessary part of their own preventive care.
"I have a hard time telling my patients [over 30], 'I'll see you in three years.' They tell me they want to come in for the pap smear every year and I'm not going to fight it. But [given the new guidelines], eventually insurance companies will stop paying for it," says Dr. Jacques Moritz, director of gynecology at St. Luke's-Roosevelt Hospital in New York.
"We have indoctrinated women with guilt and other things to go to the GYN every year and what has that done? It's brought the rate of cervical cancer way down, but that makes women feel bad now if they don't go every year and get a pap smear," he adds.
Of course, all of this hinges on the patient being asymptomatic, something that some gynecologists don't think can always be deemed by patient self-report.
"For example, women assume 'discharge' is normal ... other women assume that incontinence is 'normal'," says Dr. Joanna Cain, chair of Brown University's Department of Obstetrics and Gynecology. "The author presumes that these "symptoms" will be picked up and an exam done -- but that isn't really the case."
But just because pelvics and pap smears are not needed every year does not mean that women should see their gynecologist annually and that women shouldn't be quizzed concerning possible symptoms or overall health, Shepherd says.
"The focus should be not on the fact that paps aren't needed but that annual visits are needed, in which women discuss preventative measures go for mammograms and have other screening -- these visits just don't necessarily necessitate a pelvic."