Every year, millions of women make that annual trek to their gynecologist, internist or family doctor, and reluctantly climb into the stirrups and put up with a less-than-comfortable and — let’s face it — sometimes humiliating exam. No one likes going to the gynecologist (I don’t take this personally!), and most women are thrilled when they are told that after age 50 it is no longer necessary.
Before you permanently delete your gynecologist’s number from your contact list, let me explain the flaw behind that recommendation. In 2014, the American College of Physicians (internists, not gynecologists) issued a statement that there was no value in an annual pelvic exam unless someone had a “specific complaint.” But common sense will tell you that “no complaint” does not mean “no problem.”
Their conclusion that an annual exam was unnecessary was based on a study issued by the U.S. Preventive Services Task Force Statement that looked at only four — that’s right, four — conditions: ovarian cancer, bacterial vaginosis, trichomoniasis and genital herpes. They inexplicably concluded that since there was no benefit to a pelvic exam in diagnosing those specific conditions, an annual pelvic exam need not be performed for otherwise healthy women. This advice is reinforced by the recommendation that a Pap test is unnecessary in low-risk women over the age of 65. This argument is so beyond the most basic logic.
There are three major flaws to this reasoning.
Many conditions have no symptoms.
I cannot count the number of patients I have seen, with no complaints, that had a condition that was discovered during my routine pelvic exam. As an example, vaginal cancer occurs in only 1 per 100,000 women per year, but often goes undetected since there are no symptoms in early stages. The only way to diagnose it early is by peeking inside your vagina (it usually starts way in the back). Face it, who other than your gynecologist is going to look inside your vagina? Your gynecologist also routinely looks at your external genitalia to check for skin changes that may indicate cancer, precancer or conditions that increase the risk of cancer. Lichen sclerosus, a treatable dermatologic condition, is often asymptomatic — a condition which when untreated can lead to vulvar cancer. In addition, the bimanual exam (one hand on your belly and two fingers in your vagina) can detect masses in your pelvis from colon or other nongynecologic cancers. It has been well established that ovarian cancer is not detected on annual exams. If you are concerned about ovarian cancer, talk to your doctor about strategies for prevention, early detection and testing.
Many women are not aware that a specific symptom may indicate a serious and/or solvable problem.
Most women assume that there’s no treatment for painful sex or vaginal dryness, so they don’t bother to mention it. A woman may assume her urinary or bowel incontinence is an inevitable consequence of aging and frequent the diaper aisle instead of getting appropriate treatment. Vulvar cancer is the fourth most common gynecologic malignancy — causing 800 deaths each year — and occurs almost exclusively in women who are postmenopausal. Usually, vulvar cancer or precancer manifests itself as an itchy white patch of skin that doesn’t go away. But most women don’t know that and assume their vulvar itching is yeast, or simply skin irritation. Melanoma, basal cell carcinoma, adenocarcinoma and sarcomas can also occur on the vulva, but if no one looks, no one is going to find them. It’s not just about cancer detection. If you are menopausal, your gynecologist is the expert who will give recommendations to deal with symptoms such as hot flashes, insomnia, weight gain. He or she is the one who has the most experience dealing with hormone therapy and alternatives. Sexual dysfunction and sexually transmitted infections are also on the long list of gynecologic problems that most internists rarely address.
The “No Pap” recommendation can be incorrect.
Some experts argue that the recommendation to stop Pap tests at age 65 is also a flawed recommendation since according to a 2018 study as many as 20 percent of cervical cancer cases occur in women 65 and older. Even more problematic is that a Pap is a specific test to screen for cervical cancer and is not synonymous with pelvic exam. Many women assume that if a Pap is not needed, there is no need for a gynecological exam — even though a visual inspection of the cervix, vagina and vulva is beneficial. Your annual gynecologic exam is not only an opportunity to discuss below-the-belt issues with an expert, but also your opportunity to be reassured that everything is normal instead of treating your genitalia like some kind of no-fly zone that’s only examined if you have excruciating pain, a zoo-like odor, or bleeding requiring a change of pad every 10 minutes.
And yes, even if you have had a hysterectomy, you are not off the hook. You may not have a uterus, but you still have a vagina, vulva and repercussions of menopause that are beyond what your internist is capable of, or willing to address. So, from my point of view, it’s clearly worth the brief discomfort of a thorough exam to make sure that all is well.
Margeaux Walter
