Is a bimanual examination necessary?

From the Guidelines

A bimanual examination is not necessary for routine preventive care in asymptomatic women with no risk factors, as current guidelines have moved away from requiring regular bimanual exams due to the lack of benefit and potential harms associated with the procedure. The American College of Physicians (ACP) recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women, citing moderate-quality evidence that the harms outweigh any demonstrated benefits 1. This guideline is focused on screening asymptomatic women, and full pelvic examination with bimanual examinations is indicated in some nonscreening clinical situations, such as evaluating pelvic pain, abnormal bleeding, suspected pelvic masses, pregnancy complications, or certain gynecological conditions.

The decision to perform a bimanual examination should be based on the patient's symptoms, medical history, and clinical presentation rather than as a universal requirement. Healthcare providers should explain the purpose and process of the exam to patients and obtain appropriate consent before proceeding, as the procedure can cause discomfort and anxiety for some individuals. The ACP found no evidence that screening pelvic examination in asymptomatic, nonpregnant, adult women provides any benefit and indirect evidence that it does not reduce morbidity or mortality rates 2. Additionally, the examination can lead to unnecessary laparoscopies or laparotomies, fear, anxiety, embarrassment, pain, and discomfort, and possibly prevents women from receiving medical care.

Some key points to consider when deciding whether to perform a bimanual examination include:

• The patient's symptoms and medical history
• The clinical presentation and potential benefits of the examination
• The potential harms and risks associated with the procedure
• The patient's preferences and values
• The availability of alternative diagnostic methods, such as imaging studies or laboratory tests. The ACP guideline suggests that screening for chlamydia and gonorrhea can be done using nucleic acid amplification tests on self-collected vaginal swabs or urine, which are highly specific and sensitive, and do not require a speculum examination 3. Overall, the decision to perform a bimanual examination should be individualized and based on the specific clinical situation, taking into account the potential benefits and harms of the procedure.

From the Research

Necessity of Bimanual Examination

• The necessity of a bimanual examination is not universally agreed upon, with some studies suggesting it may be beneficial in certain situations, while others indicate it may not be necessary for asymptomatic women 4, 5.
• A study published in 2019 found that pelvic examination, including bimanual examination, may be beneficial in asymptomatic women at average risk for cervical cancer, as it may add value to cervical cytology screening and provide an opportunity for patient education and practitioner skill maintenance 4.
• However, another study published in 2018 found that the decision to perform a pelvic examination, including bimanual examination, should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider, and that it should only be performed when indicated by medical history or symptoms 5.

Benefits and Harms of Bimanual Examination

• A study published in 1994 found that bimanual pelvic examination and transvaginal sonography are equally accurate in detecting endometriosis, but that transvaginal sonography may be more informative when the uterine surface and ovaries are involved 6.
• A systematic review published in 2018 found that pre-referral pelvic examination in symptomatic women appears to be under-performed, despite urgent suspected cancer referral guideline recommendation to do so, and that it may be associated with reduced diagnostic delay and early stage diagnosis 7.
• However, the same review found that there is limited evidence on the quality of pelvic examination performed in primary care, and that no papers explored GPs' competence at performing pelvic examination directly 7.

Practice and Beliefs of Obstetrician-Gynecologists

• A study published in 2013 found that nearly all obstetrician-gynecologists perform bimanual pelvic examinations in asymptomatic women across the lifespan, although it is viewed as less important for a newly sexually active 18-year-old 8.
• The same study found that reasons cited as very important for performing bimanual pelvic examinations included adherence to standard medical practices, patient reassurance, detection of ovarian cancer, and identification of benign uterine and ovarian conditions 8.