Objective
Less-than-annual cervical cancer screening is now recommended for most US women, raising questions about the need for routine annual bimanual pelvic examinations. Little is known about clinicians’ bimanual pelvic examination practices, their beliefs about its importance, or the reasoning underlying its performance in asymptomatic women.
Study Design
We conducted a nationwide survey of US obstetrician-gynecologists. Respondents (n = 521) reported their examination practices and beliefs based on vignettes for asymptomatic women across the lifespan.
Results
Nearly all obstetrician-gynecologists perform bimanual pelvic examinations in asymptomatic women across the lifespan, although it is viewed as less important for a newly sexually active 18-year-old. Reasons cited as very important included adherence to standard medical practices (45%), patient reassurance (49%), detection of ovarian cancer (47%), and identification of benign uterine (59%) and ovarian (54%) conditions.
Conclusion
Obstetrician-gynecologists perform bimanual pelvic examinations in the vast majority of asymptomatic women, but the importance placed on the examinations and reasons for conducting them vary.
Recent recommendations by the American Cancer Society and the US Preventive Services Task Force (USPSTF) endorse less-than-annual cervical cancer screening for most women in the United States. Subsequently, the need for annual bimanual pelvic examinations among asymptomatic women has been questioned. The Institute of Medicine report on Clinical Preventive Services for Women includes annual well-woman visits, but whether or not these visits should include a routine bimanual pelvic examination has not been established. In August 2012, the American Congress of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion on well-woman visits and reaffirmed its recommendation that pelvic examinations, including bimanual examination, be included in the annual assessment for women aged ≥21 years. Despite its prominent position in well-woman care, little is known about the clinical circumstances under which clinicians perform bimanual pelvic examinations, the reasons these examinations are being performed, and the importance clinicians place on them. To address these uncertainties, we surveyed a random sample of practicing obstetrician-gynecologists to obtain estimates on their practices and beliefs regarding bimanual pelvic examinations in asymptomatic women.
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Materials and Methods
Sample
A national probability sample of obstetrician-gynecologists currently working in the United States was drawn from the American Medical Association’s (AMA) Physician Masterfile, a comprehensive database of nearly 1 million physicians that includes both members and nonmembers of the AMA and is updated weekly. A sample of at least 500 eligible respondents was targeted to achieve population estimates with at least ±5% precision. A simple random sample of 1020 practicing gynecologists (ie, not retired, not in residency, currently providing patient care, specializing in obstetrics and gynecology or gynecology alone) was drawn using a random number generator. The response rate was calculated using a standard formula in which ineligible clinicians were subtracted and adjustments made for an estimated proportion of eligible participants among unknown respondents.
Data collection and measurement
Clinicians were sent a letter introducing the study, followed 10 days later by a survey and cover letter, postage-paid return envelope, and $10 in cash. A reminder postcard was mailed 1 week later. A second cover letter, copy of the survey, and postage-paid return envelope was sent 2 weeks after the postcard if the original survey had not yet been returned. If mail was returned as undeliverable, research staff used online state medical boards, directories, and search engines to locate current information and confirm a correct mailing address. After the final mailing, recruitment efforts were continued by telephone. Data were collected from May 2010 through January 2011. The Committee on Human Research at the University of California, San Francisco, approved the study protocol.
Outcome variables
Clinicians were asked to indicate whether they would conduct a bimanual examination (with or without rectal examination) in patient vignettes of women aged 18, 35, 55, and 70 years ( Table 1 ). Their characteristics were defined such that, according to current (at the time of survey) guidelines, they were not in need of a Pap test at the visit. The vignettes are described in Table 1 . For each, clinicians were asked about a number of components of gynecological examination, and then asked about their importance, rated with 4 response categories: very important, moderately important, a little important, and not important. The clinical services listed were: (1) Pap test, (2) human papillomavirus test, (3) visual inspection of the external genitalia, (4) speculum examination, (5) bimanual pelvic examination without rectal examination, and (6) bimanual pelvic examination with rectal examination. We created an outcome variable to compare those clinicians who would conduct bimanual pelvic examination (with or without rectal examination) for the patient vignette and considered it very important, compared to all other responses.
| Patient 1 | An 18-y-old woman presents to you for a routine health visit. She became sexually active 1 mo ago. She has no history of dysplasia, is not immunocompromised, has no symptoms, and is not pregnant. |
| Patient 2 | A 35-y-old woman with no new sexual partners in last 5 y presents for a routine health visit. She has had 3 consecutive normal annual Pap tests with you, last of which was 1 y ago. She has no history of dysplasia, is not immunocompromised, has no symptoms, and is not pregnant. |
| Patient 3 | A 55-y-old woman presents to you for a routine health visit. Her cervix and ovaries were removed last year at time of hysterectomy for symptomatic fibroids. She has no history of dysplasia, is not immunocompromised, and has no symptoms. |
| Patient 4 | Healthy 70-y-old woman presents to you for a routine health visit. She has had annual Pap tests with normal findings for past 30 y. She has not been sexually active for last 10 y. She has no history of dysplasia, is not immunocompromised, and has no symptoms. |
Clinicians also were asked to rate potential reasons for conducting bimanual pelvic examinations for asymptomatic women using the same 4-point importance response scale to answer the question: “In your opinion, how important is the bimanual pelvic examination in women without symptoms?” Its importance for detection of ovarian cancer, uterine cancer, cervical cancer, subclinical pelvic inflammatory disease, benign uterine or ovarian conditions, uterine position, adherence to standard medical practice, and nonclinical reasons such as accommodating patient expectations, reassuring patients of their health, and ensuring adequate compensation was measured. The questions were designed to evaluate general reasoning underlying the performance of these examinations and were not related specifically to the vignettes.
Provider characteristics
Measures of the characteristics of clinicians included age, gender, and race/ethnicity. The practice setting was measured with an item that permitted multiple responses. These were coded hierarchically as follows: university-based, solo, or stand-alone practice; group practice; and hospital-based or other (community or family planning clinic, locum tenums, health maintenance organization). Additional measures describing the practice setting include clinic volume, the proportion of patients having public health insurance (eg, Medicaid, Medicare), region of the country, and whether the practice was in a metropolitan area, according to zip code–based Rural-Urban Commuting Area Codes.
Analysis
Comparisons for categorical variables were conducted with Fisher exact tests. Adjusted odds ratios and 95% confidence intervals from multivariable logistic regression models examining the independent associations of provider characteristics with reasons for conducting the examination for asymptomatic women were computed. Variables relevant to clinical practices were included in the model, and parsimony was achieved by excluding some variables that were not significant in bivariate models (eg, race/ethnicity, teaching hospital admitting privileges, urban location, proportion of low-income patients). All analyses were conducted with statistical software (STATA, version 11.1; Stata Corp, College Station, TX).
Results
Of 1020 surveys mailed, eligibility could be determined for 716. Of these, 590 were eligible, 63 declined participation, and 6 submitted incomplete surveys. Assuming a similar proportion of eligible respondents among the unknowns (82%), 250 eligible respondents were added to the denominator for the response rate calculation (590 + 250). The survey response rate, therefore, was 62%, with 521 eligible respondents. Respondents were no different than nonrespondents by region of the country, urban location, or gender, but were younger (34% of nonrespondents age ≥60 years vs 23% of respondents). Ninety percent of respondents were members of ACOG. Seventy percent of physicians performed >30 gynecological examinations per week and the mean number of gynecologic patients per week was 85 ( Table 2 ).
| Characteristic | % (n) |
|---|---|
| Sex | |
| Male | 54.7 (285) |
| Female | 45.3 (236) |
| Age, y | |
| 30-39 | 20.0 (104) |
| 40-49 | 31.1 (162) |
| 50-59 | 27.1 (141) |
| ≥60 | 21.9 (114) |
| Race/ethnicity | |
| White, non-Hispanic | 74.0 (376) |
| Black, non-Hispanic | 7.5 (38) |
| Hispanic/Latino | 8.3 (42) |
| Other | 10.2 (52) |
| Region of country | |
| West | 25.1 (131) |
| Midwest | 22.3 (116) |
| South | 30.9 (161) |
| Northeast | 21.7 (113) |
| Urban location | 86.4 (449) |
| Member of ACOG | 89.6 (466) |
| Specialty | |
| Obstetrician-gynecologist | 81.2 (422) |
| Gynecologist only | 18.9 (98) |
| No of gynecologic examinations/wk | |
| <30 | 30.6 (159) |
| ≥30 | 69.4 (361) |
| Mean no. of patients/wk (SD) | 85.2 (46.6) |
| Proportion of patients using public insurance | |
| <25% | 49.9 (259) |
| 25-50% | 32.4 (168) |
| >50% | 17.7 (92) |
| Proportion of low-income patients | |
| <25% | 54.6 (283) |
| 25-50% | 28.2 (146) |
| >50% | 17.2 (89) |
| Practice setting | |
| Solo or stand alone | 24.6 (128) |
| Group | 42.2 (219) |
| University based | 11.0 (57) |
| Hospital based, community, family planning clinic, or other | 23.3 (116) |
| Admitting privileges at teaching hospital | 55.7 (289) |
Nearly all obstetrician-gynecologists would conduct bimanual pelvic examinations in routine visits with asymptomatic women across the lifespan for the vignettes presented ( Figure 1 ). Nearly all respondents indicated that they would perform the examination in the 55-year-old despite the absence of her ovaries, uterus, and cervix, and over half believed it to be very important for this woman. The proportion believing the examination to be very important varied by age: about one-third (36%) viewed the examination as very important for the 18-year-old compared with 69% believing the same for the 70-year-old. For the 18-year-old patient, older physicians were significantly more likely to place high importance on the examination than younger physicians (data not shown). Respondents practicing in the Northeast and the South were more likely than those in the West to consider the examination very important for each of the patients ( Table 3 ). Clinicians in solo practice were also more likely to place high importance on the examination.
| Provider characteristics | Identify cancers of ovaries | Detect benign uterine conditions | Reassure patients of their health | Accommodate patient expectations | Ensure adequate compensation |
|---|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Age, y | |||||
| 30-39 | REF | REF | REF | REF | REF |
| 40-49 | 0.6 (0.3–1.0) | 0.7 (0.4–1.2) | 1.0 (0.6–1.7) | 1.0 (0.6–1.7) | 0.9 (0.5–1.6) |
| 40-59 | 1.2 (0.6–2.0) | 1.0 (0.5–1.7) | 1.2 (0.7–2.2) | 1.3 (0.7–2.3) | 0.7 (0.4–1.4) |
| ≥60 | 1.3 (0.7–2.5) | 1.0 (0.5–1.9) | 1.4 (0.8–2.7) | 1.5 (0.8–2.8) | 0.7 (0.3–1.6) |
| Female sex | 1.1 (0.7–1.6) | 0.9 (0.6–1.3) | 0.7 (0.5–1.1) | 0.8 (0.5–1.2) | 0.6 (0.4–1.0) |
| Region | |||||
| West | REF | REF | REF | REF | REF |
| Midwest | 1.1 (0.7–1.9) | 1.1 (0.7–1.9) | 1.5 (0.9–2.6) | 1.5 (0.9–2.6) | 1.4 (0.7–2.8) |
| South | 0.9 (0.6–1.5) | 1.1 (0.7–1.8) | 1.9 (1.2–3.1) a | 1.5 (0.9–2.4) | 1.9 (1.0–3.5) a |
| Northeast | 1.4 (0.8–2.4) | 1.5 (0.9–2.5) | 2.3 (1.3–4.0) b | 1.8 (1.1–3.2) a | 1.8 (0.9–3.4) |
| Clinical setting | |||||
| Solo practice | REF | REF | REF | REF | REF |
| Group practice | 0.6 (0.4–1.0) a | 0.6 (0.4–1.0) a | 0.4 (0.3–0.7) b | 0.8 (0.5–1.3) | 0.7 (0.4–1.2) |
| University based | 0.4 (0.2–0.7) b | 0.4 (0.2–0.7) b | 0.3 (0.1–0.5) c | 0.8 (0.4–1.7) | 0.9 (0.4–2.0) |
| Hospital/clinic, other | 0.4 (0.2–0.7) b | 0.6 (0.4–1.1) | 0.4 (0.2–0.7) b | 0.8 (0.5–1.4) | 0.7 (0.4–1.4) |
| Patients with public insurance <25% | 0.8 (0.6–1.2) | 1.1 (0.8–1.6) | 1.0 (0.7–1.4) | 1.5 (1.0–2.2) a | 1.3 (0.8–2.0) |
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