My friend glanced at me anxiously. The spitting tutor was puce, veins popping out of his neck, a cartoon characterisation of anger. Odd that a small word like “why” could cause such an allergic reaction. But “why” is the most important word in medicine. So why do doctors routinely conduct gynaecological bimanual and speculum examinations? I visited the gleaming spired evidence websites for guidance, but was left scrabbling around the waste paper bins of the internet.
Consider bimanual pelvic examination. It can detect pelvic masses, but what is the chance of making an error? In gynaecology patients under general anaesthesia one in three masses were missed, and the error was much higher for missing adnexal masses.1 If we extrapolate this finding into a conscious population with a low prevalence of disease then the risk of false positives and false negatives is so unacceptably high as to make bimanual examination next to useless as a screening tool.
Bimanual examinations are also conducted to elicit “cervical excitation,” the traditional red flag in pelvic inflammatory disease. But cervical excitation is so completely non-specific as to be of no value as a screening test.2 Therefore, in wealthier countries bimanual examination has no routine role in primary care settings. Women should have rapid definitive investigation, such as ultrasound. (Indeed, technology can convert a smartphone into a basic ultrasound machine, so our educational energies would be better spent teaching ultrasound to students.) And any women presenting with signs of pelvic peritonism should be managed with a high index of suspicion and a low threshold for referral.
Consider speculum examinations. This examination clearly has a role when examining the cervix or removing a retained tampon. Speculum examinations are often conducted for the common problem of vaginal discharge, but the evidence suggests that this is unnecessary. Most discharge is physiological and patients need simple reassurance. The common infections of bacterial vaginosis and candidiasis are self limiting but often recurrent, so empirical treatment is a reasonable approach.
Should a definitive diagnosis be needed then a self taken lower vaginal swab is a logical alternative to speculum obtained swabs. With respect to chlamydia and gonorrhoea, the widely available non-culture techniques mean that self taken vaginal samples are more sensitive than traditional culture from speculum endocervical swabs,3 4 particularly in primary care settings with delays in processing samples. Therefore, the investigation of vaginal discharge without pelvic tenderness should be by self taken swabs without the need for routine speculum examination. This is much more acceptable to patients5 and more efficient of medical time.
Why do we continue with these invasive, unscientific, unpleasant, and illogical examinations? It’s time to recognise that these routine gynaecological examinations are bad medicine.