You might have wondered why doctors routinely perform bimanual exams (insertion of fingers into the vagina) during pelvic examinations. Well, if you asked your doctor for an explanation you might not get one because doctors themselves are a bit vague about the purpose of bimanual exams. In fact, the lack of clarity extends all the way up to the American Congress of Obstetricians and Gynecologists (ACOG), where “the reasoning behind the performance of the exam is not defined” (http://www.ajog.org/article/S0002-9378%2812%2902070-4/fulltext).
Doctors’ uncertainty about the purpose of the exam can lead to inappropriate practices, over-diagnosis, potentially harmful over-treatment and devastating outcomes. A recent research study involving 521 obstetrician-gynecologists revealed the extent of the uncertainty and lack of consistency among doctors. Doctors taking part in the research study were presented with patient scenarios and then asked whether or not they would perform a bimanual exam.
The first scenario involved an 18 year old female who was there for a routine health visit, had become sexually active one month ago, had no history of dysplasia, had no symptoms, and was not pregnant. Doctors were asked if they would perform a bimanual exam on this 18 year old female and the vast majority (87%) indicated that yes, they would perform the exam. This is alarming because apparently the majority of doctors are unaware that exams are not recommended by ACOG in asymptomatic females under the age of 21.
In another scenario doctors were presented with a 55 year old woman who had come in for a routine health visit. Her cervix and ovaries had been removed one year earlier at time of hysterectomy for fibroids. She had no history of dysplasia and no symptoms. In spite of the absence of all reproductive organs, and even though ACOG’s current guidelines recommend against exams on women who have had a total hysterectomy, almost all of the doctors indicated they would perform a bimanual exam on this patient.
Of the 521 obstetrician-gynecologists involved in the study, 47% believed that bimanual exams were very important in the detection of ovarian cancer. This is in direct contrast to the ACOG endorsement that ovarian cancer screening is not recommended. Ovarian cancer screening is not recommended based on research which shows that the harms of screening outweigh the benefits. Some of the harms include unnecessary surgeries following a false-positive diagnosis, unnecessary psychological distress, and harmful over-treatment.
The research findings regarding doctors’ uncertainty about bimanual exams and their inappropriate overuse of the exam helps highlight the need for further education. The lack of clarity among doctors regarding the purpose of the bimanual exam at least helps to explain many doctors’ silence and failure to offer women informed consent or an explanation prior to performing the exam.
Thank you to Karen for her enlightening comments and references:http://forwomenseyesonly.com/2013/04/19/sexual-abuse-under-guise-of-health-care-presents-barriers/comment-page-1/#comment-27383