Pelvic exams are a standard part of OB/GYN care, but for the past several decades, their utility and ethics have been called into question. In particular, pelvic exams that are performed under anesthesia before surgery have drawn high levels of scrutiny from not only patients, but also ethicists and the medical community at large
Patient Autonomy and Informed Consent
Patient autonomy generally trumps medical necessity: Patients are free to decline medical care, as long as they are intellectually capable of making decisions on their own behalf. The physician may offer pertinent information and make recommendations, but the patient ultimately makes the decision to accept the recommended care.
Informed consent, as described by the American Medical Association, includes explaining a medical intervention to a patient, including the risks and benefits; making sure they understand what they've been told; asking the patient whether they agree to the treatment; and documenting this process within the medical record. Informed consent also lets patients know what other options are available, such as a whether there are alternatives to a pelvic exam.
Informed consent is a process of communication between a doctor and patient — not just a signature on a form. The journal Bioethics states that failing to get informed consent violates a patient's autonomy and rights, and can damage their trust in healthcare providers.
Pelvic Exams Under Anesthesia
Providers frequently ask for consent for simple, necessary procedures, such as stitching a wound. The patient needs to have the wound closed, but they also need to be told about infection risks and treatment alternatives, such as gluing or stapling. Considering that pelvic exams can be uncomfortable, embarrassing or even triggering for LGBTQIA+ individuals or survivors of sexual assault, it seems obvious that providers should ask for consent. But the problem of nonconsensual pelvic exams has a long and checkered history.
The practice of performing pelvic exams on anesthetized women for teaching purposes first began to come under scrutiny in the 1960s, according to JAMA Forum. The article calls this practice a "stain on the history of medical education," and points out that nonconsensual pelvic exams are still conducted. Medical students who practice on anesthetized women awaiting surgery are often not told whether the women consented to serve as teaching tools, and many women do not learn until afterward that their unconscious bodies have been examined by multiple students without their knowledge.
While some states have enacted laws prohibiting pelvic exams under anesthesia without consent, it is generally not legally addressed.
When Exams are Necessary
As medical technology advances, the need for pelvic exams is falling away. For example, 3D ultrasound is a less invasive tool for diagnosing pelvic pain than bimanual exams. Ultrasound is also superior in diagnostic capability and costs less than other imaging modalities such as MRI.
The American College of Obstetricians and Gynecologists (ACOG) categorizes pelvic exams as screening exams for asymptomatic women, and only recommends them in select "diagnostic" situations, such as abnormal bleeding or vaginal bulge. ACOG also recommends pelvic exams before certain procedures like endometrial biopsy or IUD placement.
ACOG notes that the American College of Physicians stopped recommending bimanual pelvic exams for ovarian cancer screening in 2014 after research showed that they "did not decrease ovarian cancer morbidity and mortality rates."
Discussing Consent With Patients
Whether or not your state requires obtaining consent before performing a pelvic exam, you should be aware that many patients expect it. ACOG reports that in a study of 452 women, 94 percent believed their doctors should discuss the benefits and risks of a pelvic exam beforehand.
The American Institute of Ultrasound in Medicine (AIUM) recommends obtaining informed consent as well. Their guidelines recommend going a step further and reviewing any ultrasound procedures with the patient, since they may be unfamiliar with the technology.
Remember that your patients who do not understand the care they receive, especially vaginal exams, can leave the office feeling frustrated or even violated. Using the informed consent process can help the provider check patient understanding, identify concerns or questions and make sure they agree to all aspects of a procedure.