We read with interest the review titled 'Bad medicine: gynaecological
examinations'. We agree wholeheartedly that every examination should be
questioned for the benefit it produces. For a given presentation,
examinations help a clinician to either find a cause or to rule out other
common/serious causes. The reviewer seems to have concentrated on only the
first part i.e. finding the cause and not ruling out other conditions.
It is well known that symptoms in gynaecology have considerable
overlap for different pathologies including non-gynaecological conditions.
On a yearly basis we pick up a few cases of undiagnosed pelvic masses
(uterine fibroids/ ovarian masses) in patients referred for symptoms such
as incontinence or vaginal prolapse who have not had a gynaecological
examination in primary care. Early diagnosis of uterine fibroids is
probably not essential, but it could make a big difference if the mass was
an ovarian malignancy. Whilst excluding masses of 3-4 cm would be
difficult in both primary and secondary care, a simple bimanual
examination could certainly rule out a large mass and more importantly
instigate rapid referral if such a mass was detected. I feel that most
patients would rather undergo a gynaecological examination if they are
made aware of some of the serious conditions it may help rule out.
Currently providing ultrasound scans and training is expensive. Most
units are struggling to meet the existing demand for ultrasound scans. Can
we justify the vast increase in scan requests when it is used to replace a
bimanual examination in the community?
STIs are but one of the several causes of vaginal discharge. A
gynaecological examination may help rule out other causes for vaginal
discharge like cervical ectropian/ cervicitis, cervical polyps and rarely
cervical malignancy
The Faculty of family planning and reproductive healthcare recommends
empirical treatment for vaginal discharge, based on symptoms, without
taking swabs at first presentation may be given only when patient is low
risk for STIs and without symptoms indicative of upper reproductive tract
infection (1).
Cervical motion tenderness, uterine or adnexal tenderness are included in
the minimum criteria for diagnosing PID and initiating empiric therapy,
which obviously cannot be assessed without a bimanual examination (2, 3).
Culture methods (HVS/Endocervical swabs) are not a total write-off as the
author suggests. Non culture tests for Chlamydia and gonococcal infections
have a limitation that they do not provide antimicrobial susceptibility
results. In cases of suspected or documented treatment failures culture
methods are indeed recommended (2).
Gynaecological examinations provide useful clinical information which
helps with patient management. We accept that some indications do change
with newer diagnostic tools, but to label gynaecological examinations as
'bad medicine' is sound bite journalism and sending out the wrong message.
REFERENCES
1.The management of women of reproductive age attending non-genitourinary
medicine settings complaining of vaginal discharge. Journal of Family
Planning and Reproductive Health Care 2006; 32(1): 33-42
2.Sexually Transmitted Diseases Treatment Guidelines 2010. Centers for
Disease Control and Prevention. Morbidity and Mortality Weekly Report,
December 17, 2010 / Vol. 59 / No. RR-12
3.UK National Guideline for the management of Pelvic Inflammatory Disease
2011 (British Association for Sexual Health and HIV)
Rapid Response:
Gynaecological Examinations- Wrong message
We read with interest the review titled 'Bad medicine: gynaecological
examinations'. We agree wholeheartedly that every examination should be
questioned for the benefit it produces. For a given presentation,
examinations help a clinician to either find a cause or to rule out other
common/serious causes. The reviewer seems to have concentrated on only the
first part i.e. finding the cause and not ruling out other conditions.
It is well known that symptoms in gynaecology have considerable
overlap for different pathologies including non-gynaecological conditions.
On a yearly basis we pick up a few cases of undiagnosed pelvic masses
(uterine fibroids/ ovarian masses) in patients referred for symptoms such
as incontinence or vaginal prolapse who have not had a gynaecological
examination in primary care. Early diagnosis of uterine fibroids is
probably not essential, but it could make a big difference if the mass was
an ovarian malignancy. Whilst excluding masses of 3-4 cm would be
difficult in both primary and secondary care, a simple bimanual
examination could certainly rule out a large mass and more importantly
instigate rapid referral if such a mass was detected. I feel that most
patients would rather undergo a gynaecological examination if they are
made aware of some of the serious conditions it may help rule out.
Currently providing ultrasound scans and training is expensive. Most
units are struggling to meet the existing demand for ultrasound scans. Can
we justify the vast increase in scan requests when it is used to replace a
bimanual examination in the community?
STIs are but one of the several causes of vaginal discharge. A
gynaecological examination may help rule out other causes for vaginal
discharge like cervical ectropian/ cervicitis, cervical polyps and rarely
cervical malignancy
The Faculty of family planning and reproductive healthcare recommends
empirical treatment for vaginal discharge, based on symptoms, without
taking swabs at first presentation may be given only when patient is low
risk for STIs and without symptoms indicative of upper reproductive tract
infection (1).
Cervical motion tenderness, uterine or adnexal tenderness are included in
the minimum criteria for diagnosing PID and initiating empiric therapy,
which obviously cannot be assessed without a bimanual examination (2, 3).
Culture methods (HVS/Endocervical swabs) are not a total write-off as the
author suggests. Non culture tests for Chlamydia and gonococcal infections
have a limitation that they do not provide antimicrobial susceptibility
results. In cases of suspected or documented treatment failures culture
methods are indeed recommended (2).
Gynaecological examinations provide useful clinical information which
helps with patient management. We accept that some indications do change
with newer diagnostic tools, but to label gynaecological examinations as
'bad medicine' is sound bite journalism and sending out the wrong message.
REFERENCES
1.The management of women of reproductive age attending non-genitourinary
medicine settings complaining of vaginal discharge. Journal of Family
Planning and Reproductive Health Care 2006; 32(1): 33-42
2.Sexually Transmitted Diseases Treatment Guidelines 2010. Centers for
Disease Control and Prevention. Morbidity and Mortality Weekly Report,
December 17, 2010 / Vol. 59 / No. RR-12
3.UK National Guideline for the management of Pelvic Inflammatory Disease
2011 (British Association for Sexual Health and HIV)
Competing interests: No competing interests