I have practiced and taught gynecology in 4 states and 5 institutions for >3 decades. While this experience does not constitute a nationwide survey, I have observed that the most common word associated with the phrase “pelvic examination” in medical charting by nongynecologists is “deferred.” This is undoubtedly a misuse of “defer” (“to put off to a future time”), since generally “defer” is actually a euphemism for “never.”

In this issue of the American Journal of Obstetrics and Gynecology , Henderson et al present the results of a nationwide survey of US obstetrician-gynecologists with 2 objectives: (1) to determine how many would complete a bimanual pelvic examination on 4 asymptomatic patients not requiring a Pap test; and (2) to determine when the examination was performed, how important it was, and why it was done. The authors demonstrate most respondents would perform the examination but the importance attached to it and the reasons for performing it varied. They also discuss why the need for the examination is not supported by evidence in any of the scenarios. This is similar to conclusions of other recent publications that challenge the value of the routine pelvic examination as part of well-women visits in the face of lengthened screening intervals for cervical cancer.

The bias of such reports is that they have a very narrow view of the indications for and components of the gynecological physical examination. For example, Henderson et al define the components of the examination to be a Pap test, human papillomavirus test, visual inspection of the external genitalia, speculum examination, and bimanual examination with or without a rectal examination, while Westhoff et al limit the putative justifications for a pelvic examination to screening for sexually transmitted disease ( Chlamydia or gonorrhea), evaluation before starting hormonal contraception, cervical cancer screening, and early detection of ovarian cancer. The latter authors concluded that “eliminating the speculum examination from most visits and the bimanual examination from all visits of asymptomatic women will free resources to provide services of proven benefit. Overuse of the pelvic examination contributes to high healthcare costs without any compensatory health benefit.”

I would agree that if one has a limited ability to make pertinent observations during the performance of the pelvic examination, the examination is better deferred. If a provider believes the only value of the pelvic examination is to obtain cervical cytology every 3-5 years, then, predictably, many potentially useful observations are never made because the examiner’s mind is not prepared to make them. As Pasteur famously observed, “chance favors the prepared mind” (In French, the quotation is: Dans les champs de l’observation le hasard ne favorise que les esprits prepares); one who approaches the pelvic examination with only the goal of exposing the cervix misses the opportunity to make pertinent observations that may benefit the patient.

Such tunnel vision allows vulvar cancers to be overlooked for years, evidence of embarrassing vaginal infections to be ignored, and an appreciation of advancing pelvic organ prolapse to be missed. Findings during the pelvic examination may lead to further questions regarding conditions such as urinary incontinence, fecal incontinence, dyspareunia and other sexual dysfunction, and physical abuse, all of which are frequently not volunteered by women but have substantial impact on their quality of life.

A pelvic examination by a qualified professional includes inspection of the external genitalia, a visual assessment of vaginal and cervical secretions with a conscious assessment as to whether they are appropriate for the individual patient and with a microscopic evaluation as indicated, an assessment of pelvic support and of the trophic status of the vaginal epithelium, an assessment of introital and vaginal pain and levator muscle tenderness, and a determination of the patient’s ability to contract and relax the pelvic floor.

The recommendation to educate clinicians about the inappropriateness of a pelvic examination for women who had a total abdominal hysterectomy–bilateral salpingo-oophorectomy ignores the fact that hysterectomy is one of the primary risk factors for pelvic organ prolapse and that detection of early prolapse may lead to simple interventions (eg, physical therapy to optimize pelvic muscle tone; fiber therapy to correct constipation and excessive straining with bowel movements) that may allow the patient to avoid surgery in the future.

Before declaring the obsolescence of the pelvic examination (and for that matter, most or all of the general physical examination) for asymptomatic women (and men), I agree with Henderson et al that other aspects of the examination deserve study to assess their value and importance. At the same time, we need to train students that the pelvic examination should be more than a Pap smear and bimanual examination.