Upton Sinclair said, “It is difficult to get a man to understand something when his salary depends on his not understanding it.” This sentiment explains much of our health care crisis. Take for instance the routine pelvic exam. Most of our patients are under the impression that an annual, routine pelvic exam is necessary for maintaining good health. And yet, to date there has been no evidence that routine pelvic exams in asymptomatic women are beneficial.
In March of 2017, the U.S. Preventative Task Force (USPTF) examined the available data and determined that it could not conclude that routine pelvic exams in asymptomatic women were necessary. (It is important to emphasize that this does not refer to cervical cancer screening.) Soon after the USPTF recommendation, the American College of Physicians and the American Academy of Family Physicians also concluded that routine pelvic exams are not necessary. Additionally, as of 2020, the American College of Obstetricians and Gynecologists agreed that routine pelvic exams in asymptomatic women may not be necessary. Despite these recommendations, most women are still being encouraged to get an annual pelvic exam. And some gynecologists are still doing routine pelvic exams on women under the age of 21. While it may be tempting to suggest that there is no harm in it, this may not be true.
Many factors influenced how American women went from seeing a gynecologist only if they had a problem to seeing a gynecologist every year. The American Cancer Society (ACS) started promoting Pap smear screening in the 1960s. It was clear that women who were screened with a Pap smear had a lower rate of cervical cancer. What was not clear at that time was exactly how often to do the Pap smear. Coincidentally, the early 1960s was also when hormonal birth control became available, so many women started seeing their gynecologists every year to have their prescriptions renewed. Without any scientific evidence to support the recommendation, the ACS suggested Pap smears be done yearly along with the birth control renewal visit.
Over time, the false notion that a pelvic exam and Pap smear were necessary for birth control became ingrained in the minds of women and doctors. As younger women started using birth control, doctors began doing Pap smears on those as young as 14 — something I have observed in my own residency training. We now know that Pap smears in young women led to the overtreatment of cervical problems, and that many young women were subjected to unnecessary biopsies and procedures, some even causing infertility issues.
Routine pelvic exams in all women, not just those on birth control, became an established event when health insurance coverage switched from the conventional fee-for-service plans to HMOs and high deductible health plans over 30 years ago. At the time of this shift in health care coverage, there was tremendous anxiety on the part of gynecologists that patients would only be able to see a gynecologist with a referral from a PCP. The new health insurance plans would provide patients with the ability to see their PCP once a year as part of their covered health services. Concerned that gynecologists’ incomes would decrease, the American College of Obstetrics and Gynecology lobbied aggressively for ob/gyns to be considered PCPs so that patients could see them without a referral. As a result, an annual visit to the gynecologist was covered by the new health insurance plans.
What managed health care has taught us is that if something is free, patients will want it regardless of whether or not they need it. Even when Pap smear guidelines were updated and the recommendation became a Pap smear every three years in average-risk women, women were still using their annual gynecological exam benefit because it was covered. Patients generally feel like they are receiving better care if a test of some sort is performed.
Furthermore, as doctors came to rely on the steady stream of income from the annual visit, they continued to perform Pap smears annually in order to make the patient feel as though the visit was worthwhile. Today, practices routinely send reminder cards to patients encouraging them to schedule their annual pelvic exam. Insurance companies also put pressure on women to schedule their annual exams. From the insurance company’s point of view, doing so is a way to justify the cost of the premiums and provide something of value to the patient. The rates of the annual exams are fixed and accounted for, so there is little to be lost on the part of the insurance company to promote them — and much to be gained in fostering the perception that they care about patients' health.
With the development of DNA technology, more accurate Pap smears became available a decade ago, ones that could be done every five years. The justification for the added expense of the newer Pap smears was that the frequency of the testing decreased, meaning they became less costly over time than the annual Pap smear. Despite the science supporting the efficacy of the newer Pap smears, I have observed that most gynecologists do not follow the new guidelines because they are afraid that patients will not come for their annuals every year, which would affect clinician income.
One of the main downsides to having an annual pelvic exam is that a patient’s chances of undergoing unnecessary testing and procedures increases. A pelvic exam can be quite inaccurate. If a doctor thinks they feel an abnormality in an asymptomatic woman, they may order an ultrasound. The ultrasound may uncover an incidental finding such as a small polyp that statistically is inconsequential. But the doctor may recommend an operative procedure to have the polyp removed. All this adds costs and increases patient anxiety, with marginal impact on patient health.
Pelvic exams are uncomfortable and intrusive. Though there are certainly situations where they are vital and necessary, such as when evaluating someone with a gynecologic problem, the routine, annual pelvic exam has not been proven to be beneficial. Having worked with gynecologists for the past 30 years, I can’t recall any of them having a routine pelvic exam unless it was for cervical cancer screening.
Doing unnecessary check ups adds to frustration for both patients and physicians. When doctors’ schedules are filled because of unnecessary annual exams, they have no openings for patients with urgent problems such as UTIs, irregular menstrual bleeding, etc. — leading to patient frustration. By the same token, gynecologists are frustrated because they have to see urgent patients in addition to an already packed schedule of annuals. As a gynecologist myself, I believe that women should be well-informed about which tests and procedures will actually improve their lives, and which ones are unnecessary. Free or not, medical exams should only be done if they fall into the former category.
Does your specialty promote a procedure you think is unnecessary? Share your perspective in the comments below!
Padma Garvey, MD is a practicing ob/gyn with over 30 years of experience. Over the past decade, she has devoted her energy and time to teaching her patients how to cook and eat a plant-based diet.
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