Gynecological Exams: Do You Still Need Them?
Several years ago, the influential U.S. Preventive Services Task Force said that most women over age 65 no longer need an annual Pap test to screen for cervical cancer—an announcement that many older women viewed as reason to forgo their yearly gynecologist appointment.
Now the USPSTF has gone a step further: In March 2017 it issued an additional recommendation stating that the “evidence is insufficient” to assess the balance of benefits and harms of pelvic examinations for most adult women to detect and treat a range of gynecologic conditions.
Taken together, do the USPSTF’s recommendations mean it’s OK to skip the annual well-woman visit that has long been a staple of preventive care?
No, according to the American College of Obstetricians and Gynecologists (ACOG) and the North American Menopause Society (NAMS). The two national organizations of women’s physicians and other healthcare experts as well as our own medical advisers stress the importance of the annual assessment as a fundamental part of women’s medical care.
While ACOG states that the annual well-woman visit is "an opportunity for the patient and her ob-gyn to discuss whether a pelvic examination is appropriate for her," the executive committee of NAMS disagrees with the USPSTF recommendation on the pelvic exam as it applies to postmenopausal women.
"Performing pelvic exams only if women complain of problems will lead to missed opportunities to diagnose disorders that become more prevalent in postmenopausal women, such as vulvovaginal atrophy, vulvar skin changes that could be precancerous, or pelvic prolapse," says JoAnn V. Pinkerton, M.D., professor of obstetrics and gynecology at the University of Virginia Health System and executive director of NAMS.
And while the incidence of cervical cancer decreases after age 55, a woman’s risk for other cancers—uterine, ovarian and breast—increases with age.
Other factors in your personal and family health history, such as whether you took hormone therapy or have a genetic risk for cancer, indicate need for continued surveillance.(Note also that the USPSTF’s statement didn’t include screenings for cervical cancer with a Pap smear, or for gonorrhea and chlamydia.)
What to expect at your visit
The scope of a well-woman visit varies from doctor to doctor, but for the most part, the visit includes these elements:
• Physical assessment. The exam typically includes an evaluation of your overall health, which includes taking vital statistics like blood pressure and body mass index (an indicator of whether your weight is at a healthy range for your height). A screening exam of other parts of your body will also be done.
• Pelvic exam. A pelvic exam involves three parts: an external examination of the vulva, an internal examination of the vagina and cervix with a speculum, and an examination of the reproductive organs with a gloved hand.
Many doctors believe that a rectovaginal examination is an integral part of the well-woman visit, which can provide additional information about rectal lesions or prolapse, for example.
In some cases, you may not need the internal portion of the exam, depending on certain factors, such as if you are asymptomatic and healthy—but the decision not to be examined should be made together with your doctor. Women who have had a simple hysterectomy may still have their ovaries, so an internal exam may reveal vaginal or pelvic problems.
Many doctors may also routinely perform a transvaginal ultrasound exam, which reveals valuable information about the ovaries and uterine lining, particularly if women have symptoms.
• Pap test. Even though most women over 65 who’ve had three normal Pap tests in a row may no longer need a test, healthy women ages 21 to 65 who have had sexual intercourse and have a cervix still need a Pap test every three years. Women with new sexual partners may need testing for sexually transmitted infections, including a Pap test and checking for human papilloma virus.
• Clinical breast exam. Your provider will inquire about your medical history and family history of breast disease, discuss your own breast self-awareness, and prompt you to schedule a mammogram.
The Task Force says the effectiveness of clinical breast exams has not been adequately proved, but many organizations recommend them. The general consensus is that clinical breast exams are an option.
The American Cancer Society recommends that women start an annual mammography at age 45 and transition to having mammograms every other year at age 55 and up, though they may choose to continue annual screening. That's because cancers tend to grow slowly and are less aggressive in postmenopausal women. Screening should continue as long as a woman is in good health, and has a life expectancy of at least 10 years.
• Evaluation of symptoms. Your gynecologist can assess any pelvic, urinary, or rectal issues, such as pain or discomfort, vaginal dryness, vaginal discharge, signs of atrophy due to lack of estrogen, urinary leakage, or bladder or bowel changes.
• Screenings and vaccinations. Time for a bone density test or a colonoscopy? Did you get your flu shot or shingles vaccine? Have you had your cholesterol checked? Your provider will likely discuss some aspects of preventive care such as these, based on your age and risk factors.
• Counseling. Expect a frank discussion about maintaining a healthy weight and active lifestyle. Your doctor will ask you what medications you’re taking, if you’ve had any change in medications or whether you’ve had a bone fracture as well as inquire about your family’s health history. He or she may also ask about your intimate relationships, describe safe sex, or ask about sexual activity and satisfaction.
Your annual well-woman exam should be an essential component of your healthcare. The benefits of a yearly visit extend well beyond a Pap test—and your doctor may be able to identify a medical problem that may otherwise go undetected.
“The well-woman exam performed regularly encompasses more than simply a screening pelvic examination, and is a fundamental part of women’s medical care," says Edward Wallach, M.D., professor emeritus of gynecology and obstetrics at the Johns Hopkins University School of Medicine in Baltimore. "It is well tolerated, and its minimal risk makes it a useful and inexpensive screening tool.”
This article originally appeared Jan. 23, 2017, and has been updated.