Letters to the Editor: Readers respond to 'Whither the bimanual examination?'

TO THE EDITOR:

Thank you, thank you, thank you. At last someone has the courage and the intelligence to speak out against the idea that most of what we ob/gyns have always done for our patients is now irrelevant or even harmful [‘Whither the bimanual examination?’ August 2014 Contemporary OB/GYN].

You don’t need me to tell you about all the asymptomatic breast masses and pelvic masses I have discovered in 35 years of practice. I thought that it could go no farther, after debasing the value of the annual Pap, but at least that had a bit of validity with HPV co-testing. Hopefully, our patients will raise their voices when we are told not to order annual mammograms or recommend DEXAs or colonoscopies. It had better be the patients who raise those voices, since the majority of my colleagues just go along like sheep in accepting so-called guidelines.

This is also not to mention the lack of support we get from our so-called representative organizations.

Joseph S. Ferroni, MD

Via email

TO THE EDITOR:

I agree with your points and in addition I would like to add the 3 cases of vaginal melanoma that I’ve found over the years on “routine” pelvic exams. I also think that the unique intimate nature of the exam and the trusted doctor-patient relationship that develops because of those yearly visits with “the laying on of hands” leads to discussions that would otherwise go unspoken about all sorts of topics like physical abuse, sexual function and dysfunction, and rectal issues that have translated into appropriate referrals and treatment. 

Dr. Dave

Posted on ContemporaryOBGYN.net

TO THE EDITOR:

Dr. Lockwood’s discussion is reasonable, if not scientifically grounded, based on the current literature until adding “free” ultrasound to the annual visit. One of the foci of the ACP position is the amount of benign “disease” we find that is not clinically relevant to the patient’s long-term well being but elicits worry, increased medical workup, and often unwarranted surgical exploration. The increased risk to the asymptomatic patient cannot be ignored. And the specious argument that this service can/will be provided “free” flies in the face of marketplace realities. In the asymptomatic patient, the greatest benefit we could offer would be early detection of ovarian cancer, one that is clearly not supported in the literature.

And the role of ultrasound in screening for cancer is similarly rejected in current studies. This may be heresy to those of us in clinical practice, but perhaps we are not employing the “Primum non nocere” principle in our current management. Random, evidence-based studies are needed to clarify how we should proceed in the future.

Dr. John P. Gallagher

Posted on ContemporaryOBGYN.net

TO THE EDITOR:

Totally agree with all your points except that finding certain pathology in asymptomatic patients is unlikely, such as endometriosis. And for internists to not do annual exams may be appropriate since I have yet to meet any who are comfortable or experienced in doing pelvic exams. As to sonography, I use TVS in all symptomatic patients as well as abnormal or questionable findings, especially in obese patients. I recall a study showing we are at best 50/50 in our bimanual exams, so a large study with “routine” TVS would be quite revealing, although I wonder about the consequences of incidental findings.

Dr. J. E. Mendez

Posted on ContemporaryOBGYN.net

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TO THE EDITOR:

As Dr. Mendez says, I, too, agree with all of your points. Thank you for clarifying an issue that these internists have certainly done a great job of obfuscating. Maybe we should do a MEDLINE analysis to demonstrate that stethoscopes are useless instruments, too?

Did someone actually pay these people to do this “research”? The emperor has no clothes on here.

Dr. Stephen Waszak

Posted on ContemporaryOBGYN.net

TO THE EDITOR:

Thank you, ACP and Annals for doing what others have tried to do for decades or centuries and that is to move back in time. Eliminating the gynecologic examination is a step back into the Victorian age or worse, and picking the failure to find early ovarian carcinoma as a reason to avoid pelvic examinations will clearly lead to loss of function and lives when parallel screening for cervical cancer and STDs is discontinued.

By curtailing female pelvic examinations there will be some short-term financial and time saving for which society will pay dearly when missed diseases bloom and grow.

Should we stop examining the heart and lungs because there are no symptoms? Eliminating the pelvic examination will [lead to] eliminating medical care and physicians, since much of what doctors do is not clearly in response to an identified illness. 

Thank you, ACP and Annals, for alerting us to a new direction. What is your next target? Reading and writing? Potable water? Garbage disposal?

Dr. Robert Wallach

Via email

TO THE EDITOR:

Dr. Lockwood, I enjoy reading your editorials every month. I particularly agree with your evaluation of the ACP article about pelvic exams. It wasn’t all that long ago that we ob/gyns were considered primary care providers for women. But it seems as though we have been relegated to being consultants. I hope you and other experts in our field can do damage control on this useless research. Thanks. 

Jeffrey T. Jones, MD

Via email

From Medical Economics: 'Routine Pelvic Exams Not Needed: ACP'