From the Guidelines
The American College of Obstetricians and Gynecologists (ACOG) recommends bimanual pelvic examination as part of comprehensive gynecologic care, though not necessarily at every visit, based on expert opinion and moderate-quality evidence 1.
Key Points
- ACOG supports bimanual examination during initial assessment, when evaluating specific gynecologic complaints, and as part of periodic well-woman visits in certain circumstances.
- The procedure allows detection of abnormalities such as masses, tenderness, or organ enlargement that might indicate conditions like fibroids, ovarian cysts, or pelvic inflammatory disease.
- However, the frequency of bimanual exams should be determined through shared decision-making between patient and provider, considering the patient's age, risk factors, and medical history.
- For asymptomatic women, especially those under 21 or not sexually active, routine bimanual exams may not be necessary at every visit, as the current evidence shows that harms outweigh any demonstrated benefits associated with the screening pelvic examination 1.
Evidence Summary
The evidence from the American College of Physicians (ACP) suggests that screening pelvic examination in asymptomatic, nonpregnant, adult women does not reduce mortality or morbidity rates, and may lead to harms such as fear, anxiety, embarrassment, pain, and discomfort 1.
Clinical Considerations
- The ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women, with a strong recommendation and moderate-quality evidence 1.
- The total annual cost of preventive gynecologic examinations and associated laboratory and radiologic services in the United States is estimated to be $2.6 billion, with Medicare payments from 2013 being $38.11 for a screening pelvic examination and $45.93 for collection of a Papanicolaou (Pap) smear specimen 1.
Recommendation
Based on the evidence, it is recommended to perform bimanual pelvic examination only when clinically indicated, and not as a routine screening test for asymptomatic women, in order to minimize harms and reduce unnecessary costs 1.
From the Research
Bimanual Examination Recommendations
- The American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic examinations be performed when indicated by medical history or symptoms 2.
- ACOG suggests that the decision to perform a pelvic examination should be a shared decision between the patient and her obstetrician-gynecologist or other gynecologic care provider 2.
- There is no evidence 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 2.
Importance of Bimanual Examination
- A survey of US obstetrician-gynecologists found that nearly all perform bimanual pelvic examinations in asymptomatic women across the lifespan, although the importance placed on the examinations and reasons for conducting them vary 3.
- Reasons cited as very important for performing bimanual pelvic examinations include detection of ovarian cancer, identification of benign uterine and ovarian conditions, patient reassurance, and adherence to standard medical practices 3.
Effectiveness of Bimanual Examination
- A systematic review found that the bimanual pelvic examination lacks accuracy as a screening test for ovarian cancer and as a way to distinguish benign from malignant lesions 4.
- The review also found that the positive predictive value of an abnormal pelvic examination is only 1% in a typical screening population 4.
Guidelines for Pelvic Examinations
- ACOG recommends routine assessments in primary and preventive care for women based on age and risk factors 5.
- 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.