Letters To The Editor

“EFFECTIVE TREATMENT OF RECURRENT BACTERIAL VAGINOSIS”
ROBERT L. BARBIERI, MD (EDITORIAL; JULY 2017)

Adverse vaginal environment can trigger vaginosis

I truly appreciated the formulaic presentation of specific regimens to attempt to eradicate recurrent bacterial vaginosis (BV), and in the future I will probably try one for a confounding case. However, although not the focus of the editorial, I found it disturbing that BV was presented as such a recalcitrant “medical” condition without emphasizing a simple understanding and approach that I have employed for the last 20 years with impressive curative results.

I have “cured” many women who have come to me after having bounced from physician to physician. Understanding that BV is not transmitted but results from an ecosystem imbalance—specifically, the lack of Lactobacillus bacteria and the overgrowth of anaerobes—any environmental manipulation that decreases the resting aerobic bacterial population can trigger the condition of vaginosis (not vaginitis).

My standard checklist, which reflects the multitude of products that pamper the modern vagina but are in fact detrimental, includes: bubble baths, which can leave a film in the vagina similar to that left in the bathtub; all forms of commercial and home-prepared douches; use of tampons extended beyond the heavy menstrual days, which can dry up the resting bacteria; repetitive immersion into a chlorinated (bactericidal) body of water (pool or hot tub); condoms that contain spermicides that are bactericidal as well; any antibacterial soap, especially fragrant liquid variants (great for the hands, awful for the vagina); fabrics like Spandex, pantyhose, and polyester that do not allow the aerobic bacteria to survive; noncotton underwear that does not let the vagina “breathe”; popular brands of scented and unscented winged pantyliners that suffocate the vaginal outlet; prolonged compression by the devoted long-distance cyclist and spa spinner; vaginal atrophy; and, anatomically, closely opposed labia, which can contribute to a chronically anaerobic vaginal environment through obstruction. When these factors are discussed and addressed, you would be surprised how much “recurrent” BV can be avoided, and therefore effectively treated.

Michael Abrahams, MD
New York, New York

Dr. Barbieri responds

I thank Dr. Abrahams for sharing his expert advice. I agree that reducing environmental exposures that inhibit the growth of vaginal lactobacilli is important in treating recurrent BV.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“EFFECTIVE TREATMENT OF RECURRENT BACTERIAL VAGINOSIS”
ROBERT L. BARBIERI, MD (EDITORIAL; JULY 2017)

Adverse vaginal environment can trigger vaginosis

I truly appreciated the formulaic presentation of specific regimens to attempt to eradicate recurrent bacterial vaginosis (BV), and in the future I will probably try one for a confounding case. However, although not the focus of the editorial, I found it disturbing that BV was presented as such a recalcitrant “medical” condition without emphasizing a simple understanding and approach that I have employed for the last 20 years with impressive curative results.

I have “cured” many women who have come to me after having bounced from physician to physician. Understanding that BV is not transmitted but results from an ecosystem imbalance—specifically, the lack of Lactobacillus bacteria and the overgrowth of anaerobes—any environmental manipulation that decreases the resting aerobic bacterial population can trigger the condition of vaginosis (not vaginitis).

My standard checklist, which reflects the multitude of products that pamper the modern vagina but are in fact detrimental, includes: bubble baths, which can leave a film in the vagina similar to that left in the bathtub; all forms of commercial and home-prepared douches; use of tampons extended beyond the heavy menstrual days, which can dry up the resting bacteria; repetitive immersion into a chlorinated (bactericidal) body of water (pool or hot tub); condoms that contain spermicides that are bactericidal as well; any antibacterial soap, especially fragrant liquid variants (great for the hands, awful for the vagina); fabrics like Spandex, pantyhose, and polyester that do not allow the aerobic bacteria to survive; noncotton underwear that does not let the vagina “breathe”; popular brands of scented and unscented winged pantyliners that suffocate the vaginal outlet; prolonged compression by the devoted long-distance cyclist and spa spinner; vaginal atrophy; and, anatomically, closely opposed labia, which can contribute to a chronically anaerobic vaginal environment through obstruction. When these factors are discussed and addressed, you would be surprised how much “recurrent” BV can be avoided, and therefore effectively treated.

Michael Abrahams, MD
New York, New York

Dr. Barbieri responds

I thank Dr. Abrahams for sharing his expert advice. I agree that reducing environmental exposures that inhibit the growth of vaginal lactobacilli is important in treating recurrent BV.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“EFFECTIVE TREATMENT OF RECURRENT BACTERIAL VAGINOSIS”
ROBERT L. BARBIERI, MD (EDITORIAL; JULY 2017)

Adverse vaginal environment can trigger vaginosis

I truly appreciated the formulaic presentation of specific regimens to attempt to eradicate recurrent bacterial vaginosis (BV), and in the future I will probably try one for a confounding case. However, although not the focus of the editorial, I found it disturbing that BV was presented as such a recalcitrant “medical” condition without emphasizing a simple understanding and approach that I have employed for the last 20 years with impressive curative results.

I have “cured” many women who have come to me after having bounced from physician to physician. Understanding that BV is not transmitted but results from an ecosystem imbalance—specifically, the lack of Lactobacillus bacteria and the overgrowth of anaerobes—any environmental manipulation that decreases the resting aerobic bacterial population can trigger the condition of vaginosis (not vaginitis).

My standard checklist, which reflects the multitude of products that pamper the modern vagina but are in fact detrimental, includes: bubble baths, which can leave a film in the vagina similar to that left in the bathtub; all forms of commercial and home-prepared douches; use of tampons extended beyond the heavy menstrual days, which can dry up the resting bacteria; repetitive immersion into a chlorinated (bactericidal) body of water (pool or hot tub); condoms that contain spermicides that are bactericidal as well; any antibacterial soap, especially fragrant liquid variants (great for the hands, awful for the vagina); fabrics like Spandex, pantyhose, and polyester that do not allow the aerobic bacteria to survive; noncotton underwear that does not let the vagina “breathe”; popular brands of scented and unscented winged pantyliners that suffocate the vaginal outlet; prolonged compression by the devoted long-distance cyclist and spa spinner; vaginal atrophy; and, anatomically, closely opposed labia, which can contribute to a chronically anaerobic vaginal environment through obstruction. When these factors are discussed and addressed, you would be surprised how much “recurrent” BV can be avoided, and therefore effectively treated.

Michael Abrahams, MD
New York, New York

Dr. Barbieri responds

I thank Dr. Abrahams for sharing his expert advice. I agree that reducing environmental exposures that inhibit the growth of vaginal lactobacilli is important in treating recurrent BV.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LAPAROSCOPIC MYOMECTOMY: TIPS FOR PATIENT SELECTION AND TECHNIQUE”
WILLIAM H. PARKER, MD (JULY 2017)

Approach for removing cervical fibroids

I thank Dr. Parker for his tips on laparoscopic myomectomy. I have one question: Should large cervical fibroids be tackled laparoscopically? If yes, then please provide some tips. Cervical fibroids are sometimes difficult to enucleate, and nothing can catch the fibroid, as the consistency is such that everything cuts through.

Manju Hotchandani, MD
New Delhi, India

Dr. Parker responds

Magnetic resonance imaging is the best imaging approach for helping to evaluate the position and size of a cervical fibroid. Fibroids that are intracervical are best removed through a vaginal approach. With the patient under adequate anesthesia, the cervix is dilated or, if necessary, incised (Dührssen incisions), and the fibroid grasped with a tenaculum. The fibroid is finger dissected away from the cervix until the pedicle is palpated. The pedicle is either clamped or ligated with suture and then cut, and the cervix is repaired.

If the fibroid is intramural/subserosal and coming off the lower uterine segment or cervix, we identify the ipsilateral ureter and follow its course near the fibroid. An incision is made over the fibroid and directed away from the ureter. It is important to incise down through the fibroid pseudocapsule and to dissect the fibroid underneath the pseudocapsule, decreasing the risk of injury to the ureter and uterine vessels. Depending on the size and position of the fibroid and the experience of the surgeon, this technique can be performed laparoscopically.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LAPAROSCOPIC MYOMECTOMY: TIPS FOR PATIENT SELECTION AND TECHNIQUE”
WILLIAM H. PARKER, MD (JULY 2017)

Approach for removing cervical fibroids

I thank Dr. Parker for his tips on laparoscopic myomectomy. I have one question: Should large cervical fibroids be tackled laparoscopically? If yes, then please provide some tips. Cervical fibroids are sometimes difficult to enucleate, and nothing can catch the fibroid, as the consistency is such that everything cuts through.

Manju Hotchandani, MD
New Delhi, India

Dr. Parker responds

Magnetic resonance imaging is the best imaging approach for helping to evaluate the position and size of a cervical fibroid. Fibroids that are intracervical are best removed through a vaginal approach. With the patient under adequate anesthesia, the cervix is dilated or, if necessary, incised (Dührssen incisions), and the fibroid grasped with a tenaculum. The fibroid is finger dissected away from the cervix until the pedicle is palpated. The pedicle is either clamped or ligated with suture and then cut, and the cervix is repaired.

If the fibroid is intramural/subserosal and coming off the lower uterine segment or cervix, we identify the ipsilateral ureter and follow its course near the fibroid. An incision is made over the fibroid and directed away from the ureter. It is important to incise down through the fibroid pseudocapsule and to dissect the fibroid underneath the pseudocapsule, decreasing the risk of injury to the ureter and uterine vessels. Depending on the size and position of the fibroid and the experience of the surgeon, this technique can be performed laparoscopically.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“LAPAROSCOPIC MYOMECTOMY: TIPS FOR PATIENT SELECTION AND TECHNIQUE”
WILLIAM H. PARKER, MD (JULY 2017)

Approach for removing cervical fibroids

I thank Dr. Parker for his tips on laparoscopic myomectomy. I have one question: Should large cervical fibroids be tackled laparoscopically? If yes, then please provide some tips. Cervical fibroids are sometimes difficult to enucleate, and nothing can catch the fibroid, as the consistency is such that everything cuts through.

Manju Hotchandani, MD
New Delhi, India

Dr. Parker responds

Magnetic resonance imaging is the best imaging approach for helping to evaluate the position and size of a cervical fibroid. Fibroids that are intracervical are best removed through a vaginal approach. With the patient under adequate anesthesia, the cervix is dilated or, if necessary, incised (Dührssen incisions), and the fibroid grasped with a tenaculum. The fibroid is finger dissected away from the cervix until the pedicle is palpated. The pedicle is either clamped or ligated with suture and then cut, and the cervix is repaired.

If the fibroid is intramural/subserosal and coming off the lower uterine segment or cervix, we identify the ipsilateral ureter and follow its course near the fibroid. An incision is made over the fibroid and directed away from the ureter. It is important to incise down through the fibroid pseudocapsule and to dissect the fibroid underneath the pseudocapsule, decreasing the risk of injury to the ureter and uterine vessels. Depending on the size and position of the fibroid and the experience of the surgeon, this technique can be performed laparoscopically.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

To the Editor: We read with great interest the article by Patnaik et al¹ about a patient who had a cardiac metastasis of ovarian cancer, and we would like to raise a few points.

It is important to clarify that metastatic cardiac tumors are not necessary malignant. Intravenous leiomyomatosis is a benign small-muscle tumor that can spread to the heart, causing various cardiac symptoms.² Even with extensive disease, patients with intravenous leiomyomatosis may remain asymptomatic until cardiac involvement occurs. The most common cardiac symptoms are dyspnea, syncope, and lower-extremity edema.

Cardiac involvement in intravenous leiomyomatosis may occur via direct invasion or hematogenous or lymphatic spread of the tumor. In leiomyoma and leiomyosarcoma, cardiac invasion usually occurs via direct spread through the inferior vena cava into the right atrium and ventricle. Thus, cardiac involvement with these tumors (except for nephroma) was reported to exclusively involve the right side of the heart.

In 2014, we reported a unique case of intravenous leiomyomatosis that extended from the right side into the left side of the heart and the aorta via an atrial septal defect.² Intracardiac extension of intravenous leiomyomatosis may result in pulmonary embolism, systemic embolization if involving the left side, and, rarely, sudden death.²

In patients with malignancy, differentiating between thrombosis and tumor is critical. These patients have a hypercoagulable state and a fourfold increase in thrombosis risk, and chemotherapy increases this risk even more.³ Although tissue pathology examination is important for differentiating thrombosis from tumor, visualization of the direct extension of the mass from the primary source into the heart through the inferior vena cava by ultrasonography, computed tomography, or magnetic resonance imaging may help in making this distinction.²

To the Editor: We read with great interest the article by Patnaik et al¹ about a patient who had a cardiac metastasis of ovarian cancer, and we would like to raise a few points.

It is important to clarify that metastatic cardiac tumors are not necessary malignant. Intravenous leiomyomatosis is a benign small-muscle tumor that can spread to the heart, causing various cardiac symptoms.² Even with extensive disease, patients with intravenous leiomyomatosis may remain asymptomatic until cardiac involvement occurs. The most common cardiac symptoms are dyspnea, syncope, and lower-extremity edema.

Cardiac involvement in intravenous leiomyomatosis may occur via direct invasion or hematogenous or lymphatic spread of the tumor. In leiomyoma and leiomyosarcoma, cardiac invasion usually occurs via direct spread through the inferior vena cava into the right atrium and ventricle. Thus, cardiac involvement with these tumors (except for nephroma) was reported to exclusively involve the right side of the heart.

In 2014, we reported a unique case of intravenous leiomyomatosis that extended from the right side into the left side of the heart and the aorta via an atrial septal defect.² Intracardiac extension of intravenous leiomyomatosis may result in pulmonary embolism, systemic embolization if involving the left side, and, rarely, sudden death.²

In patients with malignancy, differentiating between thrombosis and tumor is critical. These patients have a hypercoagulable state and a fourfold increase in thrombosis risk, and chemotherapy increases this risk even more.³ Although tissue pathology examination is important for differentiating thrombosis from tumor, visualization of the direct extension of the mass from the primary source into the heart through the inferior vena cava by ultrasonography, computed tomography, or magnetic resonance imaging may help in making this distinction.²

To the Editor: We read with great interest the article by Patnaik et al¹ about a patient who had a cardiac metastasis of ovarian cancer, and we would like to raise a few points.

It is important to clarify that metastatic cardiac tumors are not necessary malignant. Intravenous leiomyomatosis is a benign small-muscle tumor that can spread to the heart, causing various cardiac symptoms.² Even with extensive disease, patients with intravenous leiomyomatosis may remain asymptomatic until cardiac involvement occurs. The most common cardiac symptoms are dyspnea, syncope, and lower-extremity edema.

Cardiac involvement in intravenous leiomyomatosis may occur via direct invasion or hematogenous or lymphatic spread of the tumor. In leiomyoma and leiomyosarcoma, cardiac invasion usually occurs via direct spread through the inferior vena cava into the right atrium and ventricle. Thus, cardiac involvement with these tumors (except for nephroma) was reported to exclusively involve the right side of the heart.

In 2014, we reported a unique case of intravenous leiomyomatosis that extended from the right side into the left side of the heart and the aorta via an atrial septal defect.² Intracardiac extension of intravenous leiomyomatosis may result in pulmonary embolism, systemic embolization if involving the left side, and, rarely, sudden death.²

In patients with malignancy, differentiating between thrombosis and tumor is critical. These patients have a hypercoagulable state and a fourfold increase in thrombosis risk, and chemotherapy increases this risk even more.³ Although tissue pathology examination is important for differentiating thrombosis from tumor, visualization of the direct extension of the mass from the primary source into the heart through the inferior vena cava by ultrasonography, computed tomography, or magnetic resonance imaging may help in making this distinction.²

To the Editor: As a geriatric medicine fellow, I eagerly read Hagerty and Rich’s review “Fall risk and anticoagulation for atrial fibrillation in the elderly: A delicate balance”¹ and Suh’s editorial, “Whether to anticoagulate: Toward a more reasoned approach”² in the January 2017 issue. Both pieces were helpful and informative.

I appreciate that Dr. Suh encourages shared decision-making between physicians and patients that balances patient preferences and risk stratification to inform whether to anticoagulate. He states, “Unfortunately, there is no similar screening tool to predict bleeding risk from anticoagulation with greater precision in the middle to lower part of the risk spectrum...The patient’s life expectancy and personal preferences are important independent factors that affect the decision of whether to anticoagulate or not.” 

Dr. Mark Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) incorporates patients’ CHA₂DS₂-VASc and HAS-BLED scores to determine their quality-adjusted life expectancy on or off anticoagulation. The tool helps guide physicians and patients to make shared decisions about anticoagulation.^3–5 The AFDST informs clinicians if a patient is undertreated or being treated unnecessarily. Eckman and his colleagues have demonstrated the AFDST’s effective application in clinical practice, including for older adults. I invite readers to learn more about Eckman’s work!

To the Editor: As a geriatric medicine fellow, I eagerly read Hagerty and Rich’s review “Fall risk and anticoagulation for atrial fibrillation in the elderly: A delicate balance”¹ and Suh’s editorial, “Whether to anticoagulate: Toward a more reasoned approach”² in the January 2017 issue. Both pieces were helpful and informative.

I appreciate that Dr. Suh encourages shared decision-making between physicians and patients that balances patient preferences and risk stratification to inform whether to anticoagulate. He states, “Unfortunately, there is no similar screening tool to predict bleeding risk from anticoagulation with greater precision in the middle to lower part of the risk spectrum...The patient’s life expectancy and personal preferences are important independent factors that affect the decision of whether to anticoagulate or not.” 

Dr. Mark Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) incorporates patients’ CHA₂DS₂-VASc and HAS-BLED scores to determine their quality-adjusted life expectancy on or off anticoagulation. The tool helps guide physicians and patients to make shared decisions about anticoagulation.^3–5 The AFDST informs clinicians if a patient is undertreated or being treated unnecessarily. Eckman and his colleagues have demonstrated the AFDST’s effective application in clinical practice, including for older adults. I invite readers to learn more about Eckman’s work!

To the Editor: As a geriatric medicine fellow, I eagerly read Hagerty and Rich’s review “Fall risk and anticoagulation for atrial fibrillation in the elderly: A delicate balance”¹ and Suh’s editorial, “Whether to anticoagulate: Toward a more reasoned approach”² in the January 2017 issue. Both pieces were helpful and informative.

I appreciate that Dr. Suh encourages shared decision-making between physicians and patients that balances patient preferences and risk stratification to inform whether to anticoagulate. He states, “Unfortunately, there is no similar screening tool to predict bleeding risk from anticoagulation with greater precision in the middle to lower part of the risk spectrum...The patient’s life expectancy and personal preferences are important independent factors that affect the decision of whether to anticoagulate or not.” 

Dr. Mark Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) incorporates patients’ CHA₂DS₂-VASc and HAS-BLED scores to determine their quality-adjusted life expectancy on or off anticoagulation. The tool helps guide physicians and patients to make shared decisions about anticoagulation.^3–5 The AFDST informs clinicians if a patient is undertreated or being treated unnecessarily. Eckman and his colleagues have demonstrated the AFDST’s effective application in clinical practice, including for older adults. I invite readers to learn more about Eckman’s work!

In Reply: I appreciate Dr. Henning’s letter in response to my editorial.¹ Indeed, Dr. Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) is useful for determining quality-adjusted life expectancy on or off anticoagulation, and could possibly help with shared decision-making in regard to anticoagulation.^2–4 

However, the AFDST does not incorporate personal preferences regarding anticoagulant or medication use in general. Many older adults are on too many medications (ie, polypharmacy) and wish to reduce their overall pill count.

A number of potential barriers to shared decision-making regarding medication use have been identified, including poor physician communication skills, the growing number of available medications, multiple prescribers for the same patient, lack of trust in the prescribing physician, and patients feeling that their preferences are not valued or important.⁵ Until communication and acceptance between prescribers and patients regarding possible medication choices improves, shared decision-making for medication use in general and anticoagulant use in particular will be an unfulfilled ideal.

In Reply: I appreciate Dr. Henning’s letter in response to my editorial.¹ Indeed, Dr. Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) is useful for determining quality-adjusted life expectancy on or off anticoagulation, and could possibly help with shared decision-making in regard to anticoagulation.^2–4 

However, the AFDST does not incorporate personal preferences regarding anticoagulant or medication use in general. Many older adults are on too many medications (ie, polypharmacy) and wish to reduce their overall pill count.

A number of potential barriers to shared decision-making regarding medication use have been identified, including poor physician communication skills, the growing number of available medications, multiple prescribers for the same patient, lack of trust in the prescribing physician, and patients feeling that their preferences are not valued or important.⁵ Until communication and acceptance between prescribers and patients regarding possible medication choices improves, shared decision-making for medication use in general and anticoagulant use in particular will be an unfulfilled ideal.

In Reply: I appreciate Dr. Henning’s letter in response to my editorial.¹ Indeed, Dr. Eckman’s Atrial Fibrillation Decision Support Tool (AFDST) is useful for determining quality-adjusted life expectancy on or off anticoagulation, and could possibly help with shared decision-making in regard to anticoagulation.^2–4 

However, the AFDST does not incorporate personal preferences regarding anticoagulant or medication use in general. Many older adults are on too many medications (ie, polypharmacy) and wish to reduce their overall pill count.

A number of potential barriers to shared decision-making regarding medication use have been identified, including poor physician communication skills, the growing number of available medications, multiple prescribers for the same patient, lack of trust in the prescribing physician, and patients feeling that their preferences are not valued or important.⁵ Until communication and acceptance between prescribers and patients regarding possible medication choices improves, shared decision-making for medication use in general and anticoagulant use in particular will be an unfulfilled ideal.

“THE PELVIC EXAM REVISITED”
ERIN HIGGINS, MD, AND
CHERYL B. IGLESIA, MD (AUGUST 2017)

Pelvic examination is essential to clinical care

I have contemplated the issue of the routine screening pelvic exam now for several years. But for the last year, I have found various problems in many “asymptomatic women.” For example: The 18-year-old who was “not sexually active” but who had Chlamydia. Or the 84-year-old who denied itching or other vulvovaginal symptoms who had either vulvar cancer or lichen sclerosis so severe her vagina was almost closed; a 30-minute review of her outside records revealed recurrent urinary tract infections requiring more than 5 courses of antibiotics in 6 months for what was actually contaminants from a urine specimen that passed through the vagina first. I think the move away from actually touching patients has completely gotten out of hand! It is appalling how many women I have seen who visited an emergency department for pelvic or abdominal pain and never had a hands-on examination. If we do not examine the part of the body that many completely ignore we may as well lose our specialty!

Christine Kneer-Aronoff, MD
Cincinnati, Ohio

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“THE PELVIC EXAM REVISITED”
ERIN HIGGINS, MD, AND
CHERYL B. IGLESIA, MD (AUGUST 2017)

Pelvic examination is essential to clinical care

I have contemplated the issue of the routine screening pelvic exam now for several years. But for the last year, I have found various problems in many “asymptomatic women.” For example: The 18-year-old who was “not sexually active” but who had Chlamydia. Or the 84-year-old who denied itching or other vulvovaginal symptoms who had either vulvar cancer or lichen sclerosis so severe her vagina was almost closed; a 30-minute review of her outside records revealed recurrent urinary tract infections requiring more than 5 courses of antibiotics in 6 months for what was actually contaminants from a urine specimen that passed through the vagina first. I think the move away from actually touching patients has completely gotten out of hand! It is appalling how many women I have seen who visited an emergency department for pelvic or abdominal pain and never had a hands-on examination. If we do not examine the part of the body that many completely ignore we may as well lose our specialty!

Christine Kneer-Aronoff, MD
Cincinnati, Ohio

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“THE PELVIC EXAM REVISITED”
ERIN HIGGINS, MD, AND
CHERYL B. IGLESIA, MD (AUGUST 2017)

Pelvic examination is essential to clinical care

I have contemplated the issue of the routine screening pelvic exam now for several years. But for the last year, I have found various problems in many “asymptomatic women.” For example: The 18-year-old who was “not sexually active” but who had Chlamydia. Or the 84-year-old who denied itching or other vulvovaginal symptoms who had either vulvar cancer or lichen sclerosis so severe her vagina was almost closed; a 30-minute review of her outside records revealed recurrent urinary tract infections requiring more than 5 courses of antibiotics in 6 months for what was actually contaminants from a urine specimen that passed through the vagina first. I think the move away from actually touching patients has completely gotten out of hand! It is appalling how many women I have seen who visited an emergency department for pelvic or abdominal pain and never had a hands-on examination. If we do not examine the part of the body that many completely ignore we may as well lose our specialty!

Christine Kneer-Aronoff, MD
Cincinnati, Ohio

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.