The Annual Exam Myth: How We Screened Too Often, Too Early, and for the Wrong Things
Annual Pap smears. Annual pelvic exams. CA-125 for ovarian cancer screening. We ordered them for decades. The evidence said they didn’t work. We ordered them anyway.
The annual gynecologic examination was an article of faith. Every year, every woman, speculum and bimanual exam, Pap smear, and sometimes an ultrasound or a CA-125 “just to be safe.” The ritual was so ingrained in American women’s health culture that questioning it felt like questioning prevention itself.
The annual Pap smear was the centerpiece. Introduced in the 1940s after Georgios Papanicolaou demonstrated that cervical cancer cells could be detected in vaginal smears, the Pap test is one of the most successful cancer screening tools in history. Cervical cancer mortality in the United States dropped by more than 70% in the decades following the introduction of widespread screening.
But the success of the Pap smear does not mean that annual screening is the right interval. And it does not mean that every woman at every age benefits equally.
The evidence accumulated over decades: screening every 3 years with cytology, or every 5 years with HPV co-testing, is as effective as annual screening for women aged 21 to 65. Screening women under 21 causes overtreatment of transient HPV infections. Screening after hysterectomy for benign disease has virtually no yield. Routine bimanual pelvic exams do not detect ovarian cancer at a stage when detection matters. And the combination of CA-125 and transvaginal ultrasound for ovarian cancer screening does not reduce mortality. It increases surgery.
Five screening practices. Each seemed like prevention. Each failed the evidence test.
🎯 Free Subscriber Bottom Line: Five routine gynecologic screening practices have been reformed or abandoned: annual Pap smears (replaced by 3- to 5-year intervals), Pap screening in women under 21 (now deferred until age 21), continued Pap after hysterectomy for benign disease (discontinued), routine annual pelvic exams in asymptomatic women (no evidence of benefit), and CA-125 with TVUS for ovarian cancer screening (shown by the PLCO trial to cause harm without reducing mortality). The annual gynecologic ritual is not evidence-based. Targeted, risk-appropriate screening is.
Below, paid subscribers get: - The cervical screening interval evidence: why annual was never necessary - Adolescent cervical biology and why screening under 21 causes harm - The PLCO trial: the definitive failure of ovarian cancer screening - The ACP bombshell: no evidence for the routine pelvic exam - What the “well-woman visit” should actually contain - Which current screening practices might be next.
