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Women's health update: important Evaluations in Women's Health.

The Need for the Routine Pelvic Exam

In early July 2014, the American College of Physicians (ACP) issued guidelines advising against bimanual pelvic exams and speculum exams for the detection of pathological conditions in asymptomatic adult women who are not pregnant. The ACP reviewed the evidence and concluded that the routine pelvic examination is not useful in screening for malignancies other than cervical cancer, and can lead to unnecessary evaluation and surgery, while also often causing discomfort and embarrassment and even actually deterring some women from seeking gynecological care. Their recommendations are summarized as follows:

* Routine pelvic exam is not recommended in asymptomatic nonpregnant adult women.

* This recommendation does not apply to the timing and need for cervical cancer screening.

* The cervical cancer screening tests--Pap smears, liquid-based Paps, and/or human papillomavirus (HPV) testing--should include a vaginal speculum exam while visualizing the cervix and collection of samples, but does not need to include bimanual examination.

* Screening for chlamydia and gonorrhea can be done with urine tests or vaginal swabs.

The advisory from ACP has generated significant conversation, editorials, and commentary, particularly from ob/gyns. If you haven't already noticed amongst your patient population, many women have heard these news reports, assume that they are well accepted, and thus no longer seek annual pelvic exams. With the changes in Pap smear/HPV testing frequency, these ACP recommendations on annual pelvic exams, and the controversies on frequency of screening mammography, many women will conclude that they no longer need to see a physician annually for routine screening and health care. The ACP guidelines are thought by many to now add one more barrier to providing appropriate preventive health care to adult women.

In attempting to understand the pros and cons of these guidelines, it is important to look at the details of the study. This study was a literature review conducted by the Minneapolis Veterans Affairs Health Care System's Evidenced-based Synthesis Program Center. The authors were looking to assess the accuracy, benefits, and harms of screening pelvic exams; they defined a pelvic exam as a combination of speculum and bimanual exam, not including screening for HPV or cervical dysplasias/cervical cancer.

A Medline search was conducted for relevant articles published from 1946 to 2014. Their findings caused them to strongly recommend "against performing screening pelvic exams in asymptomatic, non-pregnant, adult women." The recommendations were based on moderate-quality evidence. In addition, they defined potential harm as unnecessary laparoscopies or laparotomies, fear, embarrassment, anxiety, pain or discomfort, and avoidance of necessary care. Due to the "moderate-quality evidence," some studious critics point out that this study was not a comprehensive data-analysis with strong statistical support. In this Medline search, the authors focused on ovarian cancer and bacterial vaginosis due to the fact that these were the only conditions that had sufficient published data from which to draw some of their conclusions. This resulted in not addressing and analyzing the numerous other reasons that we carry out bimanual exams; for example, detection of myomas, urinary incontinence, pelvic floor support or lack thereof, cervical polyps, vaginal wall growths, and adnexal pain and masses with the potential of indicating pelvic inflammatory disease, endometriosis, and ovarian cysts. Unfortunately, and admitted by the study authors, no studies actually directly assess the value of pelvic exams for any of these conditions. In addition, no studies have evaluated the potential benefit of annual pelvic exams in asymptomatic women on morbidity and mortality related to nonovarian and noncervical cancer. Another lacking area of published studies is the potential benefit of annual pelvic exams as the reason why women obtain care and then might thus receive other access to health-care services, including contraception, screening for sexually transmitted infections, and the vast array of nongynecological health-care needs that women have. In addition, no studies address the potential harms such as false reassurance, overdiagnosis, overtreatment, and harms related to diagnostic procedures. This was a particularly odd admission on the part of the authors in that these were the reasons that they actually recommended against routine pelvic examinations. While the authors concluded that current evidence shows that harms outweigh benefits associated with screening pelvic exams, the studies examining pain, embarrassment, and fear are of low quality.

Comment: As a naturopathic physician women's health practitioner, I think that these recommendations from the ACP are worrisome for women, and so does the American College of Obstetricians and Gynecologists (ACOG), which in 2012 reaffirmed that the speculum and bimanual examination is a part of annual well-women visits in women aged 21 years and older; that is what I practice as well.

Routine annual pelvic exams (yes, still annually, even when it is not the year to collect the Pap smear), including visualizing the external genitalia, inserting the speculum and visualizing the cervix and vaginal walls, and a bimanual exam provide a wealth of important information even in women who do not have any symptoms as stated above. Many women have bacterial vaginosis or some other vaginal or cervical infection; severe vulvovaginal atrophy; pelvic floor problems, including urinary incontinence; cervical polyps; vaginal wall cysts and growths; uterine fibroids; adnexal/ovarian enlargement for noncancerous reasons; and/or vulvar skin disorders. Any of these can occur without symptoms, and the only way that we would know it is if the full exam is performed. The asymptomatic woman is indeed the woman who might benefit most from the routine annual pelvic exam. It has been hard enough to communicate to women the need for continued annual exams (which also include height, weight, blood pressure, temperature, pulse, breast exam, thyroid exam, heart/lung/ abdominal exam, and more) even when they don't need a Pap smear or HPV test that year. Too many women have ceased seeing their health-care providers every year and only come every 3 years after they reach the age at which they no longer need an annual Pap smear.

In addition, as a naturopathic physician, I use the annual visit to check in on nutrition, alcohol, nicotine, recreational and prescription drugs, stressors, exercise, sleep, dietary supplements, other health issues, changes in their health including weight gain or weight loss, an eye toward prevention of diseases based on family history, aging, habits, and select routines or specific testing.

With these ACP recommendations (which I will ignore), I am certain that we can predict that even fewer women will seek annual visits with their health-care providers. I will encourage my patients to seek annual visits and be clear in communicating the value of each exam and each test if/when needed; and then as a result of that discussion, they can of course choose their course of action.

Bloomfield H et al. Screening pelvic examinations in asymptomatic, average-risk adult women: An evidence report or a clinical practice guideline from the American College of Physicians. Ann intern Med. 2014 Jul 1;161:46

Lockwood C. Whither the bimanual examination? Contemp Ob Gyn. 2014;5-8.

Waseem A, Humphrey L, Harris R, Starkey M, Denberg T. Clinical Guidelines Committee of the American College of Physicians. Screening pelvic examination in adult women: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(1):67-72.

Chronic Insomnia Evaluation

The etiologies for problematic sleep include primary sleep disorders such as sleep apnea, insomnia, and restless leg syndrome; midlife and aging; hormonal changes of perimenopause; medical conditions such as depression, thyroid disease, anxiety, gastroesophageal reflux, arthritis, lung disease, cancer and more; medications such as decongestants, weight-loss products, some antidepressants, blood pressure medications, steroids and diuretics; caffeine, nicotine, and alcohol; travel or work schedules; stressors; and poor sleep habits.

Determining the chief sleep symptom is the first step in the evaluation process of insomnia. The main symptoms of the insomnia may be difficulty in falling asleep, early awakening, and/or frequent nighttime awakenings. A sleep diary can be useful in identifying the sleep problems. The diary should indicate bedtimes; awakening times; timing and quantity of meals; use of alcohol, caffeine, drugs, and medications; exercise and its timing; duration of sleep; and rating of sleep quality (bed partners may help by reporting snoring). The diary should be kept daily for at least several weeks or even months in order to properly assess sleep patterns.

Specific testing might also be appropriate. Examples would include a polysomnogram, thyroid testing, ferritin (a value less than 50 might be relevant), CBC (for restless leg syndrome), endoscopy, joint imaging, and pulmonary function testing and/or chest imaging. For women of perimenopausal or menopausal age, other laboratory tests to consider, but not as a given, include follicle stimulating hormone (FSH; if menses are irregular and you are not sure of the etiology), or even serum progesterone if perimenopause is not otherwise evident from symptoms. One might also consider testing for vitamin D and MTHFR defects, which can be correlated with depression and insomnia. Progressive naturopathic testing might also include a four-point salivary cortisol test to determine cortisol dysregulation, and assessing neurochemistry with analysis of urinary neurotransmitters or their metabolites.

Ancoli-lsrael S et al. Insomnia in special populations: effects of aging, menopause, chronic pain, and depression. Postgrad Med. 2004 Dec;116(6 Suppl Insomnia):33-47.

Kravitz HM. Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women. Sleep. 2008 Jul;31(7):979-990.

Pavlova M, Sheikh LS. Sleep in women. Sernin Neural. 2011 Sep;31(4):397-403. doi:10.1055/s-0031-1293539.

by Tori Hudson, ND

Dr. Tori Hudson graduated from the National College of Naturopathic Medicine (NCNM) in 1984 and has served the college in many capacities over the last 28 years. She is currently a clinical professor at NCNM and Bastyr University; has been in practice for over 28 years; and is the medical director of the clinic A Woman's Time in Portland, Oregon, and director of research and development for Vitanica, a supplement company for women. She is also a nationally recognized author, speaker, educator, researcher, and clinician.
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Author:Hudson, Tori
Publication:Townsend Letter
Geographic Code:1USA
Date:Jan 1, 2015
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