Should ovaries be palpable on a bimanual (manual two-handed) exam?

Palpability of Ovaries on Bimanual Examination

Normal ovaries should be barely palpable or not palpable at all during a bimanual pelvic examination. 1

Normal Findings on Bimanual Examination

• During a bimanual examination, the adnexa (ovaries) are assessed for pain or masses, but normal ovaries are usually barely palpable in most women 1
• The bimanual examination is performed by inserting 1 or 2 fingers into the vagina with a water-based lubricant on the gloved hand, allowing the examiner to assess the cervix, uterus, and adnexal regions 1
• The examination should focus on identifying abnormalities rather than expecting to clearly palpate normal ovaries 1

Clinical Significance of Palpable Ovaries

• Palpable ovaries, particularly in postmenopausal women, may warrant further investigation as they can be associated with pathology 2
• Studies have shown that postmenopausal women with palpable ovaries may have increased ovarian dimensions and potentially concerning ultrasound findings including atypical follicular activity and abnormal vascularization 2
• The presence of an adnexal mass detected on bimanual examination is considered a reason for referral to a gynecologist according to clinical practice guidelines 1

Limitations of Bimanual Examination for Ovarian Assessment

• The bimanual pelvic examination has very low sensitivity (5.1%) for detecting ovarian cancer when used as a screening method in asymptomatic women 3
• In the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, bimanual examination was discontinued as a screening strategy because no cases of ovarian cancer were detected solely by this method 1
• The positive predictive value of bimanual examination for detecting ovarian cancer is less than 4% according to studies that reported this metric 1
• A study of 2,623 healthy asymptomatic women found that bimanual examination had a specificity of 99.9% for malignancy but identified no ovarian malignancies at initial screening 4

Current Recommendations Regarding Bimanual Examination

• The U.S. Preventive Services Task Force (USPSTF) concludes that there is no mortality benefit to routine screening for ovarian cancer with bimanual pelvic examination 1
• The American College of Physicians found no data supporting the use of pelvic examination in asymptomatic, average-risk women 1
• For symptomatic women with gynecologic complaints (abnormal bleeding, pelvic pain, etc.), appropriate components of the pelvic examination, including bimanual examination, should be performed to identify benign or malignant disease 5

Common Pitfalls in Bimanual Examination

• Mistaking pressure or movement for pain, particularly in adolescents or those not experienced with the examination 1
• Over-interpretation of normal anatomical variations as pathology 1
• Potential psychological harms: studies report that approximately one-third of women experience fear, embarrassment, anxiety, pain, or discomfort during or before pelvic examinations 1
• False reassurance from a normal examination, which may delay diagnosis given the low sensitivity of the examination for detecting early ovarian pathology 3

In summary, while bimanual examination remains an important clinical skill for evaluating symptomatic patients, normal ovaries should be barely palpable or not palpable at all. Distinctly palpable ovaries, especially in postmenopausal women, may warrant further investigation with more sensitive diagnostic tools such as transvaginal ultrasound.