What are the recommendations for pelvic exams in a 60-year-old woman with a history of hysterectomy (surgical removal of the uterus) but intact ovaries?

From the Guidelines

For a 60-year-old woman with a history of hysterectomy but intact ovaries, routine pelvic examinations are generally not recommended unless she has specific symptoms or risk factors. Since the uterus has been removed, there is no need for cervical cancer screening (Pap smears). However, she should still receive regular bimanual examinations to assess her ovaries every 1-3 years as part of her preventive healthcare. These exams help detect potential ovarian abnormalities, as she remains at risk for ovarian cancer with her ovaries intact. The examination should include palpation of the ovaries and assessment of the vaginal cuff (where the cervix was removed). Additionally, she should report any symptoms such as pelvic pain, bloating, vaginal bleeding, or discharge promptly, as these could indicate complications requiring evaluation.

The rationale for limited routine pelvic exams is that the benefit of screening asymptomatic women after hysterectomy is low, while the potential for anxiety, unnecessary follow-up testing, and false positives remains, as noted in the American College of Physicians guideline 1. Her healthcare provider may recommend more frequent examinations if she has a family history of ovarian cancer or other risk factors, as suggested by the USPSTF recommendations 1.

It's also important to consider the latest guidelines from the National Comprehensive Cancer Network (NCCN) 1, which provide recommendations for genetic/familial high-risk assessment and management, including surveillance and risk-reducing strategies for ovarian cancer. However, the most recent and highest quality study, 1, does not provide specific recommendations for routine pelvic exams in asymptomatic women with a history of hysterectomy and intact ovaries.

Key points to consider:

• Routine pelvic exams are not recommended for asymptomatic women after hysterectomy unless specific symptoms or risk factors are present.
• Bimanual examinations to assess the ovaries every 1-3 years may be recommended as part of preventive healthcare.
• Women with a family history of ovarian cancer or other risk factors may require more frequent examinations.
• The latest guidelines from the NCCN provide recommendations for genetic/familial high-risk assessment and management, but do not specifically address routine pelvic exams in this population.

From the Research

Pelvic Exam Recommendations for a 60-Year-Old Woman with a History of Hysterectomy but Intact Ovaries

• The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have had a hysterectomy but still have their ovaries should continue to have regular pelvic exams, but the frequency may be reduced compared to women with an intact uterus 2.
• The US Preventive Services Task Force (USPSTF) states that there is no clear evidence to support routine screening for ovarian cancer in asymptomatic women, including those with a history of hysterectomy but intact ovaries 2.
• Transvaginal ultrasound (TVU) and serum CA-125 measurement are commonly used screening tests for ovarian cancer, but their effectiveness in reducing mortality is still unclear 3, 4, 5.
• A study published in the Journal of the American Medical Association (JAMA) found that screening for ovarian cancer with TVU and CA-125 measurement did not significantly reduce mortality from the disease 2.
• The British Journal of Radiology published a review article discussing the debate on ovarian cancer screening programs and the impact of using ultrasound on reducing ovarian cancer-related mortality, concluding that more research is needed to develop effective screening strategies 5.

Screening Strategies

• TVU can identify size and morphology changes of the ovary that may signal a developing malignancy, but it has a low specificity 5.
• Serum CA-125 measurement can be used in combination with TVU to increase the accuracy of screening, but its effectiveness in reducing mortality is still unclear 3, 4.
• The Risk of Ovarian Cancer Algorithm (ROCA) is a proprietary algorithm that uses CA-125 levels, change in CA-125 levels over time, and age to estimate the risk of ovarian cancer, but its effectiveness in reducing mortality is still unclear 2.

Risks and Benefits

• Screening for ovarian cancer can lead to unnecessary surgery and major complications in women without cancer 2.
• The psychological effects of screening, including anxiety and stress, should also be considered 2.
• Further research is needed to identify effective approaches for reducing ovarian cancer incidence and mortality 2, 5.