What tests are recommended for a routine pelvic exam?

Recommended Tests for Routine Pelvic Examination

A routine pelvic examination should not include any tests unless clinically indicated by symptoms or specific risk factors, as there is insufficient evidence to support routine screening pelvic examinations in asymptomatic women. 1, 2

Components of Pelvic Examination When Indicated

When a pelvic examination is clinically indicated, the following tests may be appropriate:

Cervical Cancer Screening

• Papanicolaou (Pap) test: Should begin at age 21 regardless of sexual activity onset 1
  • Ages 21-29: Every 3 years with cytology alone
  • Ages 30+: Every 3 years with cytology alone OR every 5 years with HPV co-testing
  • Not recommended for women under 21 years regardless of sexual activity 1

STI Screening

• Nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia:
  • Can be performed on urine specimens or self-collected vaginal swabs, eliminating the need for speculum examination in asymptomatic women 1, 3
  • Should be performed based on risk factors rather than routinely

Other Tests (Only When Indicated)

• Vaginal pH and wet mount microscopy: For symptoms of vaginal discharge or suspected vaginitis 1
• Vaginal/cervical cultures: For persistent symptoms or treatment failures 1
• Bimanual examination: Not recommended as a routine screening test 3, 2

Specific Indications for Pelvic Examination

A pelvic examination should only be performed when there are specific clinical indications, including:

• Persistent vaginal discharge
• Dysuria or urinary tract symptoms in sexually active females
• Dysmenorrhea unresponsive to NSAIDs
• Amenorrhea
• Abnormal vaginal bleeding
• Lower abdominal pain
• Contraceptive counseling for IUD or diaphragm
• Suspected/reported sexual assault
• Pregnancy evaluation 1

Common Pitfalls to Avoid

1. Performing unnecessary examinations: Many providers continue to perform routine pelvic examinations despite lack of evidence supporting their use in asymptomatic women 2, 4

2. Equating pelvic examination with Pap testing: Many women believe they've had a Pap test when only a pelvic examination was performed. Clearly communicate what tests are being performed 1

3. Causing unnecessary discomfort: Approximately 30% of women experience fear, anxiety, embarrassment, pain, and discomfort during pelvic examinations 3

4. False positives leading to unnecessary procedures: Routine pelvic examinations can result in false-positive findings in approximately 1.5% of women screened 3

5. Missing pelvic pathology: Physical examination alone has limited sensitivity for detecting certain conditions; appropriate imaging or laboratory testing should be used when indicated 5

Special Considerations

• Trauma-informed approach: For patients with history of sexual trauma, who experience significantly more distress during examinations 3
• Adolescents: Examination of external genitalia should be included as part of annual comprehensive physical examination, but internal examination should be limited to specific indications 1
• Menopausal women: May require special attention due to vaginal atrophy 6
• Women with disabilities: May need adapted examination techniques 6

By limiting pelvic examinations to clinically indicated situations and using less invasive screening methods when appropriate, providers can reduce unnecessary discomfort and anxiety while still providing appropriate care that focuses on reducing morbidity and mortality.