Pelvic examinations of utmost importance

A recent headline in one of Canada's national newspapers screamed Time To End Pelvic Examinations Done Without Consent. But there should be another headline, Why Are So Many Tests Being Done Without an Examination?

Dr. Sara Wainberg reports in The Journal of Obstetrics and Gynecology that pelvic examinations are being done by medical students without the patient's permission. They were performed after patients were anesthetized prior to hysterectomy or other pelvic procedures. This gynecological learning process has been utilized for years in teaching hospitals without newspaper headlines.

The criticism is that the procedure is done without informed consent. This is a valid ethical complaint and is easily corrected by obtaining a patient's consent. But this teaching technique, to my knowledge, has never resulted in a patient's death or needless worry. And, compared to other grave ethical issues in our society, I question whether it deserves newspaper headlines, or publication in a leading medical journal.

Dr. Wainberg would be better advised to carry out a research study on wide-awake patients. How the failure to do pelvic examinations at all can cause patient deaths. Or, result in a huge amount of worry. And why so many CT scans and MRIs are being done on women rather than a pelvic examination.

I learned two important things at The Harvard Medical School. One, it is essential to listen to the patient. If you listen long enough, patients may themselves reveal the diagnosis. Two, you must examine the patient. Today, these two essential steps are taking second place to technology.

It's doesn't take rocket science to understand that it makes sense for a doctor to do a pelvic examination. After all, how would a mechanic diagnose the car's problem if he fails to open the hood? But over the years, all too often, I've seen wide-awake patients with pelvic complaints who have not had an internal pelvic examination by their doctor. This can have disastrous consequences.

As an instance, a young woman who had been practising to be a concert pianist for years was within a few months of her piano debut in Toronto. She had complained to several doctors that she had noticed increasing amounts of vaginal discharge for well over a year. Doctors had prescribed a number of medications without any effect.

Finally, she decided to get another opinion because, "none of the doctors had examined me", she explained. Unfortunately, when the pelvic examination was done she showed an advanced cancer of the cervix, which could have been treated many months earlier. She died before giving her recital.

Another woman was suffering from increasing discomfort with menstrual periods and severe pain during sexual intercourse. She had seen several doctors. The ultrasounds they prescribed had always been reported normal. Later, she was placed on birth control pills that had no affect on her pain and was told her trouble was psychological. A simple pelvic examination would have pinpointed the diagnosis -- endometriosis.

This disease is the result of internal bleeding during periods. What happens is that the lining of the uterus, normally only present in the uterus, becomes implanted on other organs inside the abdomen. So when the normal lining bleeds during a period, the abnormally displaced lining also bleeds. It's this internal bleeding that causes pain during periods and sexual intercourse.

Endometriosis may form bloodfilled ovarian cysts. These cysts can be easily diagnosed by ultrasound. But quite often this disease causes severe scarring of ligaments at the end of the vagina. It's this scarring that can cause severe pain during sex. But I've yet to see a case where this scarring can be diagnosed by ultrasound. So if a pelvic examination is not done the diagnosis will be missed and patients may be told the problem is psychological.

One of my former professors used to drum this message into his students about failing to do an internal examination. He remarked, "If you don't put your finger in, you will put your foot in it!"

Yes, I agree with Dr. Wainberg that sleeping patients should give their permission prior to a pelvic examination. But, let's also be sure that wide-awake patients get the pelvic examinations they deserve.

Republished from the Winnipeg Free Press print edition February 5, 2010 A21