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In practice

Farewell to the routine pelvic exam?

Dan Page

Thirty years later, I still remember the day I learned how to perform a pelvic examination. My teacher’s name was Josie. She was a generous soul who, probably for little more than a parking voucher and a coupon for lunch in the hospital cafeteria, agreed to let a dozen gloved pairs of fumbling medical student hands probe her insides.

Josie had “a good exam” the gynecologist supervising us said, meaning she was a good patient for students to practice on. Her fibroid tumors were so large that even second-year students could feel them. The uterine fibroids were causing Josie to hemorrhage and she would soon have a hysterectomy. One by one, as we stepped up for our awkward turn between the stirrups, we thanked Josie for helping us become doctors. She smiled, shrugged and said of the organ that had borne her children, “Hey, I figure it can do one last bit of good before I lose it.”

I imagine Josie thought her discomfort (and ours) was worthwhile. We students were, after all, acquiring an essential skill, since “the pelvic” had long been considered a necessary part of the complete annual physical exam of every female patient. Now, however, that conventional wisdom is being challenged.

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While the American College of Obstetricians and Gynecologists still endorses routine exams, the American College of Physicians, which includes internists like me, does not. Citing 60 years of data from several sources, the ACP last month recommended that doctors stop performing routine annual pelvic exams on women who are not pregnant, not due for a Pap test (which is no longer recommended annually for most women), and who have no history or symptoms of pelvic disorders.

The ACP concluded that the low chance of detecting an asymptomatic gynecologic condition — including ovarian cancer, for which no effective screening test exists — doesn’t justify the pain, fear, anxiety, and embarrassment that a high percentage of women report after having a pelvic exam.

I’ve been trying to figure out why the ACP’s announcement left me feeling a little sad.

Personally, I won’t miss the exams. One advantage of being a female physician is that when a woman says, as she slides down in her crinkly gown over the crinkly paper to the end of the table, “Ugh, I hate this!” I can credibly respond that I know how she feels.

“The lithotomy” position, in which a woman’s legs are spread and her feet positioned in metal stirrups is not only physically uncomfortable, it leaves one feeling powerless in a way that few other medical procedures do. Perhaps that’s why the exam that’s intended to protect women’s health was once seen as representing our oppression.

The 1970’s feminist manifesto, “Our Bodies, Ourselves,’’ taught women how to examine themselves by wielding their own speculum. That instrument was thereby transformed into an early symbol of the women’s movement.

In an effort to help male medical students appreciate the unique sense of vulnerability women experience during the pelvic exam, some schools have the men climb up on exam tables and, clothed, assume the lithotomy position themselves.

I cringe now to think of some of the women I’ve examined for whom the pelvic would no longer be recommended: women who had never had intercourse and for whom the exam was particularly traumatic, and, especially, a woman with cognitive impairment who associates me so closely with the dreaded pelvic that she trembles even when she comes to see me for a sore throat or earache.

I even think, with some regret, of women who would still need the exam according to current guidelines: the woman with abnormal Pap tests who’d been sexually abused as a child and who wept through every exam; the woman whose husband had been unfaithful and who told me, through gritted teeth as I screened her for sexually transmitted diseases, to please just hurry up and get it over with.

So I don’t mourn the demise of the routine pelvic exam specifically, but I do feel a growing melancholy about the decline in regard for the physical exam in general, and of which the ACP’s recent announcement is merely a reminder.

Evidence-based studies suggest that little of what I do in the exam room has measurable benefit. Maneuvers I was taught would be among my most valuable tools in medicine — palpating the liver and spleen, striking the knee with a reflex hammer, and even listening to the sounds of the heart — have been deemed a waste of time by some medical organizations.

Not everyone agrees with this assessment, and a movement to preserve the art of the physical exam, spearheaded by Stanford physician-author Abraham Verghese, among others, has arisen.

But even if physical exams aren’t as diagnostically useful as once believed, clinicians touching patients may be therapeutic.

In a Globe article about the new recommendations on pelvic exams, a gynecologist argued that, during the exam, women often mention complaints that they’re reluctant to bring up otherwise. In a recent New York Times column, Dr. Danielle Ofri described the physical exam as a “refuge,” an increasingly rare intimate and meaningful interaction between clinician and patient, away from the computer.

I know just what Ofri means. I get nervous each time the value of a physical exam is challenged. I worry that I’m one step closer to a bleak, futuristic medical apocalypse in which I don’t see or touch patients at all — I just analyze their data.

I plan to follow the ACPs recommendations. I’ll perform pelvic exams on women who are due for Pap tests or have symptoms, and I’ll tell other patients they don’t need them. But I’ll continue to provide the exam to any woman who wants one, even just for peace of mind. In doing so, I’ll be heeding the wisest words I’ve ever heard on this topic, spoken to me years ago by my own obstetrician. He said, “Every uterus I’ve ever met was attached to a person.”

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She can be reached at inpracticemd@gmail.com.
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