ACOG COMMITTEE OPINION SUMMARY

Number 754

For a comprehensive overview of these recommendations, the full-text Scan this QR code
version of this Committee Opinion is available at with your smartphone
http://dx.doi.org/10.1097/AOG.0000000000002895. to view the full-text
Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3kFt6OSS8/9JQv+Ezs2jHWNUKrkTo4exfwD3J0XTuzmM= on 01/31/2019

version of this
Committee Opinion.
Committee on Gynecologic Practice
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice in
collaboration with committee members Catherine Cansino, MD, MPH and Lubna Chohan, MD.

The Utility of and Indications for Routine Pelvic

Examination
ABSTRACT: The pelvic examination has long been considered a fundamental component of the well-woman visit,
and many women and gynecologic care providers view this visit as an opportunity to discuss sexual and reproductive
health issues. Traditionally, a pelvic examination is performed for asymptomatic women as a screening tool for
gynecologic cancer, infection, and asymptomatic pelvic inflammatory disease; some obstetrician–gynecologists and
patients consider it important in detecting subclinical disease, despite evidence to the contrary. Given changes in
screening recommendations and the ability to screen for sexually transmitted infections using less-invasive methods,
reevaluation of the role of the pelvic examination for asymptomatic, nonpregnant women is warranted. A limited
number of studies have evaluated the benefits and harms of a screening pelvic examination for detection of ovarian
cancer, bacterial vaginosis, trichomoniasis, and genital herpes. Data from these studies are inadequate to support
a recommendation for or against performing a routine screening pelvic examination among asymptomatic, nonpregnant
women who are not at increased risk of any specific gynecologic condition. It is recommended by the American College
of Obstetricians and Gynecologists that pelvic examinations be performed when indicated by medical history or
symptoms. Women with current or a history of cervical dysplasia, gynecologic malignancy, or in utero diethylstilbestrol
exposure should be screened and managed according to guidelines specific to those gynecologic conditions. Based on
the current limited data on potential benefits and harms and expert opinion, the decision to perform a pelvic examination
should be a shared decision between the patient and her obstetrician–gynecologist or other gynecologic care provider.

Recommendations and Conclusions
The American College of Obstetricians and Gynecolo-
gists (ACOG) makes the following recommendations
and conclusions regarding the use of and indications for
the pelvic examination:
c Pelvic examinations should be performed when
indicated by medical history or symptoms.
c Based on the current limited data on potential
benefits and harms and expert opinion, the decision
to perform a pelvic examination should be a shared
decision between the patient and her obstetrician–
gynecologist or other gynecologic care provider.
c A limited number of studies have evaluated the benefits
and harms of a screening pelvic examination for
detection of ovarian cancer, bacterial vaginosis, tricho-
moniasis, and genital herpes. Data from these studies
are inadequate to support a recommendation for or
against performing a routine screening pelvic exami-
nation among asymptomatic, nonpregnant women
who are not at increased risk of any specific gynecologic
condition. Data on its effectiveness for screening for
other gynecologic conditions are lacking.
c Women with current or a history of cervical dys-
plasia, gynecologic malignancy, or in utero

1080 VOL. 132, NO. 4, OCTOBER 2018 OBSTETRICS & GYNECOLOGY

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 diethylstilbestrol exposure should be screened and
managed according to guidelines specific to those
gynecologic conditions.
c After reviewing risks and benefits, the pelvic
examination also may be performed if a woman
expresses a preference for the examination.
c Regardless of whether a pelvic examination is per-
formed, a woman should see her obstetrician–
gynecologist at least once a year for well-woman care.
c A pelvic examination is not necessary before initiating
or prescribing contraception, other than an intrauterine
device, or to screen for sexually transmitted infections.

[Table 1] Pelvic Examination Recommendations

Definition of Pelvic
Organization Recommendation Examination Evidence Review

American College of Obstetrician–gynecologists and
Obstetricians and other gynecologic care providers
Gynecologists (2018) should counsel asymptomatic,
nonpregnant women about the
benefits, harms, and lack of data.
The patient and gynecologic care
provider should then decide
together if an examination will be
performed.
Assessment of the external Reviewed literature on health
genitalia; internal speculum benefits, accuracy, and harms of
examination of the vagina and the screening pelvic examination
cervix; bimanual palpation of the for gynecologic conditions
adnexa, uterus, and bladder; and
sometimes rectovaginal
examination

American College of Recommends against performing
Physicians* (2014) screening pelvic examination in
asymptomatic, nonpregnant, adult
women
Inspection of the external
genitalia; speculum examination
of the vagina and cervix;
bimanual examination of the
adnexa, uterus, ovaries, and
bladder; and sometimes rectal
or rectovaginal examination
Evaluated the diagnostic
accuracy, benefits, and harms of
pelvic examination in
asymptomatic, nonpregnant,
average-risk adult women.
Cervical cancer screening was
not included.
No studies that investigated the
morbidity or mortality benefits of
screening pelvic examination for
any condition were identified.
Diagnostic accuracy of pelvic
examination for ovarian cancer:
three cohort studies (n55,633)
Benefits of pelvic examination for
detection of malignant or benign
conditions: no studies
Direct harms: pain or discomfort:
eight studies (n54,576); fear,
embarrassment, or anxiety: seven
studies (n510,702)
Indirect harms: false reassurance,
overdiagnosis, overtreatment, or
diagnostic procedure-related
harms: no studies; indirect evi-
dence from one cohort study
(n52,000)y

American Academy Recommends against screening Endorses American College of Endorses American College of
of Family Physiciansz pelvic exams in asymptomatic Physicians recommendations Physicians recommendations; no
(2017) women independent review

Society of Offer pelvic examination to every N/A N/A

Gynecologic patient presenting for a well-
Oncology§ (2016) woman examination in the context
of a balanced discussion of the
risks and benefits.
(continued )

VOL. 132, NO. 4, OCTOBER 2018 Committee Opinion No. 754 Summary 1081

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 [Table 1] Pelvic Examination Recommendations (continued )
Definition of Pelvic
Organization Recommendation Examination Evidence Review

U.S. Preventive
Services Task Force
(2017)
Current evidence is insufficient to
assess the balance of benefits and
harms of performing screening
pelvic examinations in
asymptomatic, nonpregnant adult
women. (I grade)k
Any of the following
components, alone or in
combination: assessment of the
external genitalia, internal
speculum examination,
bimanual palpation, and
rectovaginal examination
Systematically reviewed
literature on health benefits,
accuracy, and harms of the
screening pelvic examination for
gynecologic conditions
No trials examined the
effectiveness of the pelvic
examination in reducing all-cause
mortality, reducing cancer-specific
and disease-specific morbidity and
mortality, or improving quality of
life. Eight studies reported
accuracy for the screening pelvic
examination: ovarian cancer (four
studies, n526,432); bacterial
vaginosis (two studies, n5930);
trichomoniasis (one study,
n5779); and genital herpes (one
study, n5779).¶

*Qaseem A, Humphrey LL, Harris R, Starkey M, Denberg TD. Screening pelvic examination in adult women: a clinical practice guideline from the American College of
Physicians. Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2014;161:67–72.
y
Bloomfield HE, Olson A, Greer N, Cantor A, MacDonald R, Rutks I, et al. Screening pelvic examinations in asymptomatic, average-risk adult women: an evidence report for
a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014;161:46–53.
z
American Academy of Family Physicians. Screening pelvic exam. Clinical Preventive Service Recommendation. Leawood (KS): AAFP; 2017. Available at: https://www.aafp.org/
patient-care/clinical-recommendations/all/screening-pelvic-exam.html. Retrieved June 13, 2018.
§
Society of Gynecologic Oncology. Pelvic examinations. SGO Position Statement. Chicago (IL): SGO; 2016. Available at: https://www.sgo.org/newsroom/position-statements-2/
pelvic-examinations/. Retrieved June 13, 2018.
k
Bibbins-Domingo K, Grossman DC, Curry SJ, Barry MJ, Davidson KW, Doubeni CA, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services
Task Force Recommendation Statement. US Preventive Services Task Force. JAMA 2017;317:947–53.
¶
Guirguis-Blake JM, Henderson JT, Perdue LA. Periodic screening pelvic examination: evidence report and systematic review for the US Preventive Services Task Force. JAMA
2017;317:954–66.

Full-text document published online on September 24, 2018.

Copyright 2018 by the American College of Obstetricians and

Gynecologists. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, posted on the Internet,
or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written
permission from the publisher.
Requests for authorization to make photocopies should be directed to
Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA
01923, (978) 750-8400.

American College of Obstetricians and Gynecologists

409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Official Citation
The utility of and indications for routine pelvic examination. ACOG
Committee Opinion No. 754. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2018;132:e174–80.

1082 Committee Opinion No. 754 Summary OBSTETRICS & GYNECOLOGY

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It
is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the
reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG
Resource Center.
While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy,
reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or
person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities,
including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential
conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.
org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by
those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the
development of the content of this published product.

VOL. 132, NO. 4, OCTOBER 2018 Committee Opinion No. 754 Summary 1083

Copyright ª by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.