Voices: Negotiating the pelvic exam

Negotiating the pelvic exam | B.J. Rimel, MD

Lately, I’ve been hearing a great deal of negotiating in my office. Now that I’ve been in practice for two years, I’m getting to see some patients back for surveillance visits and unfortunately some for recurrence. Regardless of the reason for the visit the strategy is always the same: is there a way to avoid the pelvic exam portion of the visit? In an attempt to discuss the reasons why we, as gynecologic oncologists, perform what is inevitably an uncomfortable examination, I will answer the top 5 things said in my office after I say, “I’m going to step out now so you can undress.”
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  1. “Do we really need to do an exam?” Yes, for cancers that can recur in the pelvis, a pelvic examination can detect very small lesions at the top of the vagina, in the rectum, in the space between the vagina and rectum and sometimes even in the bladder. Does that mean that a patient has to do something she does not want to do? NO! Any person can refuse any examination or procedure. But early detection of a recurrence in this area may allow for curative treatment. This is what we all want. And focusing on this goal can really help get through a difficult exam. Note: A pelvic exam can only evaluate the areas that we can see with our eyes (with the speculum) or feel with our hands. For most gynecologic cancers this is the most likely site that the cancer may return, but of course, cancer can return almost anywhere.
  2. “Can I just get a CT scan?” The simple answer is “Maybe. I’ll tell you if you need one right after this exam.” In the absence of symptoms or concerning findings on the physical exam (including the pelvic exam) it is not currently recommended to have surveillance imaging. There are a few exceptions to this, but in general, if a person is feeling well and has a normal physical examination, then routine imaging studies (like CT scan or PET or even MRI) are not likely to be beneficial. In fact, they are expensive and time-consuming and if you have a lot of them it may result in more radiation than a person really needs.
  3. “Is there a blood test for this?” No. Or perhaps, more accurately, not yet. There is not currently a biomarker that replaces a pelvic exam.
  4. “My other doctor never does one.” Hmmm. This is tricky. If your other doctor is an orthopedic surgeon, then yes, they probably don’t. If your other doctor is a medical oncologist, then perhaps you are here in my office for exactly this reason, because one of the responsibilities of the gynecologist oncologist is to assess the status of your gynecologic cancer; even if that assessment means confirming your cancer is not detectable.
  5. “Ugh. I really hate this part.” Yes. I know. I wish it were easier. I (and my gynecologic oncology colleagues) will do everything I can to make the exam as swift and painless as possible. Tell me if you are in pain and I will stop. If it helps, I will tell silly jokes, or help you meditate, or tell you in detail exactly what I’m doing and what I see (or don’t see) or be completely silent if that is your wish. For me, I wish that when people came into the office they were happy to see me, but that is the life of the gynecologic oncologist.

As a gynecologic oncologist, the pelvic exam plays a critical role in my ability to diagnose and treat gynecologic cancer. Nobody enjoys it. It is as disliked as going to the dentist, having a colonoscopy or getting a parking ticket. As a human being, I feel that the pelvic exam is one of the most challenging and vulnerable of exams. It must be approached with the utmost respect and with humility. But it is necessary. It is important.