What are the indications for a pelvic exam?

From the Guidelines

Pelvic exams are indicated for symptomatic women, such as those with abnormal vaginal bleeding, pelvic pain, or suspected pelvic inflammatory disease, as well as for pregnant women, and those requiring diagnosis and management of conditions like endometriosis, ovarian cysts, and genital tract infections. The decision to perform a pelvic exam should be based on the individual patient's symptoms and medical history, rather than as a routine screening measure for asymptomatic women 1.

Indications for Pelvic Exam

• Evaluation of gynecological symptoms, including abnormal vaginal bleeding, pelvic pain, vaginal discharge, or suspected pelvic inflammatory disease
• Pregnancy, for assessment of cervical dilation and effacement during labor
• Diagnosis and management of conditions like endometriosis, ovarian cysts, uterine fibroids, and genital tract infections
• Prior to inserting intrauterine devices or fitting diaphragms
• For sexual assault victims, to collect evidence and assess injuries

The American College of Physicians (ACP) guideline recommends against routine pelvic examination in asymptomatic, average-risk, nonpregnant women 1. The evidence suggests that routine pelvic examinations may cause pain, discomfort, fear, anxiety, or embarrassment in about 30% of women, with no clear benefits in terms of reduced mortality or morbidity rates 1.

Key Considerations

• The exam allows healthcare providers to directly visualize the external genitalia and vagina, palpate internal reproductive organs, and collect specimens when necessary
• Proper positioning, clear communication, and gentle technique can minimize patient discomfort during the exam
• The decision to perform a pelvic exam should be based on the individual patient's symptoms and medical history, rather than as a routine screening measure for asymptomatic women 1.

From the Research

Indications for Pelvic Exam

The indications for a pelvic exam can be summarized as follows:

• Pelvic examinations should be performed when indicated by medical history or symptoms 2
• 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 2
• Any woman with gynecologic complaints, including vulvar complaints, vaginal discharge, abnormal premenopausal bleeding, postmenopausal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, new and unexplained gastrointestinal symptoms, pelvic pain, or dyspareunia, should undergo appropriate components of the pelvic examination to identify benign or malignant disease 3
• Health care practitioners should perform cervical cytology cancer screening in accordance with provincial/territorial guidelines 3
• There is insufficient evidence to guide recommendations on screening pelvic examination for noncervical gynecologic malignancy or any benign gynecologic disease in healthy, asymptomatic women with average risk of malignancy 3

Asymptomatic Women

• Health care practitioners may consider performing a screening pelvic examination including visual, speculum, and bimanual examinations in concert with cervical cytology sampling intervals as recommended by provincial/territorial guidelines 3
• Women over age 70 who no longer require screening with cervical cytology may benefit from continuing periodic screening of asymptomatic women for vulvar disease with inspection of the vulva, perineum, and anus to identify benign or malignant disease unrecognized by this population 3
• Women with a personal history of gynecologic malignancy, a genetic diagnosis that increases gynecologic malignancy risk, or a history of in utero diethylstilbestrol exposure may benefit from more frequent screening pelvic examinations to identify early primary, recurrent, or metastatic malignancy in the absence of symptoms 3

Symptomatic Women

• Any woman with gynecologic complaints should undergo appropriate components of the pelvic examination to identify benign or malignant disease 3
• Non-invasive and self-collection screening options for chlamydia and gonorrhea are acceptable in asymptomatic women, but pelvic examination, including visual inspection, speculum examination, and bimanual examination, is required in the presence of symptoms to rule out pelvic inflammatory disease or tubo-ovarian abscess 3

Special Considerations

• Routine pelvic examinations should be re-considered in asymptomatic patients, as they have low rates of abnormalities detected on examination 4
• Maximizing comfort should be the goal of the pelvic examination, particularly in adolescent and menopausal women, sexual minorities, obese women, women with disabilities, and women with a history of trauma or prior instrumentation affecting the genitalia 5