Speculum and bimanual examinations of little benefit
Does every woman who requests an STI check require speculum and bimanual examinations? This is a very valid question indeed; what would be the value of subjecting every woman to an invasive examination when little information or benefit can be gained?
This has been investigated by a cross-sectional study on a database of attendees of two GUM clinics in the United States.
Women were stratified on the basis of presenting reason. The likelihood of invasive examination to yield findings that meant diagnosis of an STI or referral for further management were calculated.
Nearly 16,000 records were included. The majority of patients (more than 12,000) were symptomatic, while the rest were either asymptomatic or had known contact with a partner with an STI.
Of those with symptoms, 11.8% were more likely to have clinically significant findings on speculum examination compared with women with known contact with a partner with an STI (4.6%) or asymptomatic patients (3.9%).
Bimanual examination detected clinically abnormal findings in 6.5% of symptomatic attendees compared with 0.8% of women with STI contact and 0.6% of asymptomatic patients.
Based on this retrospective data, there appears to be little gain from performing speculum and bimanual examinations. However, the authors note prospective studies are needed to determine if omitting invasive examinations would offer any operational advantage without compromising safety.
It would be relevant to primary care if we could screen for STIs in asymptomatic women with urine or self-taken samples. Advances in molecular technology mean that we can now do less invasive testing for organisms such as chlamydia and gonorrhoea; in primary care, we are under constant pressure to use our time effectively.
However, anecdotal evidence from many doctors and nurses suggests that speculum examination for, say, cervical cytology, may provide an opportunity for the patient to bring up difficult concerns, such as psychosexual problems.
Perhaps we need to empower some patients to bring up these concerns without waiting for an invasive examination.
Singh RH, Erbelding EJ, Zenilman JM, et al. The role of speculum and bimanual examinations when evaluating attendees at a sexually transmitted diseases clinic. Sex Transm Infect 2007;83:206-210reviewerreviewer Reviewer
Dr Richard Ma
GP principal, North London and staff grade in sexual and reproductive health, Margaret Pyke Centre, London