For clinicians working to refine outpatient gyn care, a model of learning with CoP creates a space to move beyond theory and into practical implementation. CoP have been shown to move knowledge into practice within small scale contexts to help overcome the knowledge practice gap. The evidence collectively suggests that the ongoing, relational nature of CoP, as opposed to one-time educational events, is what enables clinicians to move from knowledge acquisition to sustained practice change.
Historically, the “annual exam” included exactly that – an exam every year, usually with a pap smear. Today, this practice is no longer common, as gynecology practitioners and our governing bodies have acknowledged that this may be more harmful than beneficial and evidence just doesn’t stack up in favor of routinely examining people anymore. Additionally, with cervical cancer screening (Pap) guidelines having shifted to a longer interval for many low-risk individuals, a Pap may not be done for 3-5 years for someone, which also supports ditching the exam portion of what we now refer to as the “annual visit”.
Current guidelines recommend that pelvic exams be performed when indicated by medical history or symptoms, which is how many of today’s clinicians practice. The reason for this is that evidence for routine exam is limited and studies evaluating the benefits and harms of screening pelvic examinations for detection of ovarian cancer, bacterial vaginosis, trichomoniasis and genital herpes (just to name a few) are inadequate to support a recommendation for or against routine screening in asymptomatic, average-risk women/people (ACOG 2018).
For example, pelvic exams have not been shown to decrease ovarian cancer morbidity and mortality (ACOG 2018) and the “normal” assessment of ovaries during bimanual exam is to simply say you couldn’t feel them, aka “non palpable”. However, annual well visits are still recommended, regardless of whether a pelvic exam is performed, as this provides an opportunity to discuss sexual and reproductive health, review screening needs and determine whether a pelvic exam is appropriate.
So, why are we talking about it? Guidelines seem pretty clear.
Because of something I heard a physician say, which was that newer practitioners are not getting the experience of knowing what is normal vs abnormal since we’re doing so many fewer exams in current practice. Obviously, this doesn’t mean we should go back to just examining without a good indication, but it could be a great space for shared decision making and transparency that you, as a newer or less experienced practitioner, would like to be more comfortable examining and evaluating healthy anatomy. I think what many of us found during our training is that there are many, many patients out there happy to help us learn, so it isn’t unreasonable to simply have the conversation with the person and explain to them what the guidelines say and let the patient guide the conversation (and certainly the decision) from there.
Why Some Patients Still Expect an Annual Exam
For many people—especially those from generations when yearly pelvic exams and Pap smears were standard—annual screening still feels like an essential part of preventive care. As clinicians, we may be more comfortable with today’s extended screening intervals than patients who had a Pap every year for most of their adult lives and may not be familiar with updated ACOG and ASCCP guidance.
This difference in expectations can lead to exams that may not be medically necessary, but still feel important to the patient. Some people are comfortable following current guidelines and foregoing annual Pap testing or screening beyond age 65 when they are low risk; others may need more discussion, reassurance, or time to adjust to the change.*
Ultimately, shared decision making is key, but the patient who wants the exam regardless of the guidelines should have the exam, and this can be a great time for a newer or less experienced practitioner to become more comfortable evaluating anatomy in an asymptomatic individual.
References:
ACOG Committee Opinion No. 754: The Utility of and Indications for Routine Pelvic Examination. Obstetrics and Gynecology. 2018. Committee on Gynecologic Practice (Guideline)
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