European Journal of Obstetrics and Gynecology 291 (2023) 131–140

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.journals.elsevier.com/european-journal-of-obstetrics-and-gynecology-and-
reproductive-biology

Full length article

Pelvic exam in Gynecology and Obstetrics: French Guidelines for

Clinical Practice
Xavier Deffieux a, *, Anne-Cécile Pizzoferrato b, c, Laurent Gaucher d, e, f, g,
Christine Rousset-Jablonski h, Camille Le Ray i, Thierry Brillac j, Julia Maruani k,
Lorraine Maitrot-Mantelet l, Stéphanie Mignot m, Yoann Athiel i, Hortense Baffet n,
Alexandre Bailleul o, p, Valérie Bernard q, Mathilde Bourdon r, Claire Cardaillac s,
Yaritza Carneiro t, Patrick Chariot u, v, Romain Corroenne w, Yohann Dabi x, Laurence Dahlem y,
Sophie Frank z, Anne Freyens aa, Virginie Grouthier ab, ac, Isabelle Hernandez ad,
Elisabeth Iraola ae, af, Marie Lambert q, ag, Nadege Lauchet ah, Guillaume Legendre ai, aj,
Maela Le Lous ak, al, Christine Louis-Vahdat am, Anne Martinat Sainte-Beuve an, Marine Masson m,
Caroline Matteo ao, Anne Pinton ap, aq, Emmanuelle Sabbagh l, Camille Sallee ar,
Thibault Thubert as, at, Isabelle Heron au, av, France Artzner aw, Arounie Tavenet ax,
Adrien Gantois ay, Arnaud Fauconnier o, p
a
Université Paris-Saclay, AP-HP, Hôpital Antoine Béclère, Service de gynécologie obstétrique, Clamart F-92140, France
b
Service de Gynécologie Obstétrique, Hôpital Universitaire de La Miletrie, Poitiers F-86000, France
c
INSERM CIC 1402, Université de Poitiers, Poitiers F-86000, France
d
Collège National des Sages-Femmes de France, CNSF, Paris F-75010, France
e
Public Health Unit, Hospices Civils de Lyon, Bron F-69500, France
f
INSERM U1290, Research on Healthcare Performance (RESHAPE), Université Claude Bernard, Lyon 1, Lyon F-69008, France
g
Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, 1206 Geneva, Switzerland
h
Centre Léon Bérard, Département de Chirurgie, et Centre Hospitalier Lyon Sud, Service de Gynécologie-Obstétrique, INSERM U1290 RESHAPE, Lyon F-69000, France
i
Maternité Port Royal, Groupe Hospitalier Paris Centre, APHP, Université Paris Cité, FHU Prema, Paris F-75014, France
j
Département de médecine générale, Toulouse F-31000, France
k
Cabinet Médical, 6 Rue Docteur Albert Schweitzer, Marseille F-13006, France
l
Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Unité de gynécologie médicale, hôpital Port-Royal, Paris F-75014, France
m
Département de médecine générale, Poitiers F-86000, France
n
Service de gynécologie médicale, orthogénie et sexologie, CHU de Lille, Université de Lille, Lille F-59000, France
o
Service de Gynécologie Obstétrique, Center Hospitalier de Poissy Saint Germain en Laye, Poissy F-78300, France
p
Equipe RISCQ « Risques cliniques et sécurité en santé des femmes et en santé périnatale », Université Paris Saclay, UVSQ, Montigny le Bretonneux F-78180, France
q
Service de chirurgie gynécologique, gynécologie médicale et médecine de la reproduction, centre Aliénor d’Aquitaine, Centre Hospitalo-Universitaire Pellegrin, Bordeaux
F-33000, France
r
Université Paris Cité, APHP, Center Hospitalier Universitaire (CHU) Cochin Port Royal, Service de Gynécologie Obstétrique II et Médecine de la Reproduction, F-75014,
France
s
Service de gynécologie-obstétrique, CHU de Nantes, Nantes F-44000, France
t
Cabinet de médecine générale, Faye l’Abbesse F-79350, France
u
Département de médecine légale et sociale, Assistance Publique - Hôpitaux de Paris, Bondy F-93140, France
v
Institut de Recherche Interdisciplinaire sur Les Enjeux Sociaux, UMR 8156-997, UFR SMBH, Université Sorbonne Paris Nord, Bobigny F-9300, France
w
Service de gynécologue-obstétrique, CHU Angers, Angers F-49000, France
x
Sorbonne université – APHP – Hôpital Tenon, Service de gynécologie obstétrique et médecine de la reproduction, Paris F75020, France
y
Département universitaire de médecine générale, Faculté de médecine, Université de Bordeaux, 146 rue Léo Saignat, Bordeaux F-33076, France
z
Service d’oncogénétique, Institut Curie, Paris F-75005, France
aa
DUMG (Département Universitaire de Médecine Générale), Université Paul Sabatier, Toulouse F-31000, France
ab
Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, Bordeaux, France
ac
Univ. Bordeaux, Inserm U1034, Biology of Cardiovascular Diseases, Pessac, France
ad
Département de maïeutique, Center hospitalier de Melun Santepole, Melun F-77000, France
ae
Institut de Recherche interdisciplinaire sur les Enjeux Sociaux (IRIS), UMR 8156-997, CNRS U997 Inserm EHESS UP13 UFR SMBH, Université Sorbonne Paris Nord,
Paris, France

* Corresponding author.
E-mail address: [email protected] (X. Deffieux).

https://doi.org/10.1016/j.ejogrb.2023.10.007
Received 31 August 2023; Received in revised form 18 September 2023; Accepted 6 October 2023
Available online 10 October 2023
0301-2115/Published by Elsevier B.V.
X. Deffieux et al. European Journal of Obstetrics & Gynecology and Reproductive Biology 291 (2023) 131–140

af
Direction de la protection maternelle et infantile et promotion de la santé, Conseil départemental du Val-de-Marne, Créteil F-94000, France
ag
Université de Bordeaux, Bordeaux Institute of Oncology - Unité Inserm 1312, Bordeaux F-33000, France
ah
Groupe Médical François Perrin, 9 rue François Perrin, Limoges F-87000, France
ai
Service de gynécologue-obstétrique, CHU Angers, Angers F-49000, France
aj
UMR_S1085, Université d’Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
ak
Université de Rennes 1, INSERM, LTSI - UMR 1099, Rennes F-35000, France
al
Département de gynécologie et obstétrique, CHU de Rennes, Rennes F-35000, France
am
Cabinet de gynécologie et obstétrique, 126 Boulevard Saint Germain, Paris F-75006, France
an
Cabinet médical, 177 Rue DE VERSAILLES, Le Chesnay-Rocquencourt F-78157, France
ao
Cabinet de maïeutique, 181 rue du Docteur Cauvin, Marseille F-13015, France
ap
Service de gynécologie obstétrique, Hôpital Trousseau, APHP, 26, avenue du Dr-Arnold-Netter, Paris F-75012, France
aq
Sorbonne Université, Paris F-75013, France
ar
Service de Gynécologie-Obstétrique, Hôpital Mère-Enfant, CHU de Limoges, Limoges F-87000 France
as
Service de Gynécologie-Obstétrique, CHU de Nantes, Nantes F- 44000, France
at
Laboratoire Mouvement, Interactions, Performance (MIP), EA 4334, Nantes Université, Nantes F- 44322, France
au
Service d’endocrinologie, Université de Rouen, Hôpital Charles Nicolle, Rouen F-76000, France
av
Cabinet médical, 7 rue de Lessard, Rouen F-76100, France
aw
CIANE, Collectif interassociatif autour de la naissance, c/o Anne Evrard, 101 rue Pierre Corneille, Lyon F-69003, France
ax
ENDOFRANCE, Association de lutte contre l’endométriose. 3 rue de la Gare, Tresilley F-70190, France
ay
Collège National des Sages-Femmes de France hébergé au Réseau de Santé Périnatal Parisien (RSPP), Paris F75010, France

Introduction agreement and 3 an expert consensus agreement. Thirteen questions

resulted in an absence of recommendation due to lack of evidence in the
Pelvic clinical exam (gynecological examination) can provoke literature.
discomfort, pain, distress and/or negative physical and emotional
symptoms such as anxiety, fear and embarassment. Health professionals, Results
and the society as a whole, are questioning its justification and recon­
sidering and the methods used to carry out pelvic examination (insertion How to learn & teach pelvic exam, and how to perform
of a speculum and vaginal examination) as part of women’s medical
care. Apprehension of a routine pelvic exam (particularly for young Question 1 - For a health professional in initial training, does
women on their first appointment, women survivors of violence and learning the pelvic examination (vaginal examination and insertion of
women with chronic pelvic or perineal pain) can lead to avoiding or a speculum) through simulation (anatomical model, patient-teachers)
delaying/postponing a consultation, which could lead to a loss of op­ provide superior skills compared to traditional teaching (theoretical
portunity (lack of hygiene advice, absent or delayed prevention (for learning and mentoring)?
example in terms of contraception), delayed diagnosis or screening, A meta-analysis (9 series including 4 randomized controlled trails
etc.). (RCTs), showed that simulation training using low-fidelity anatomical
Scientific societies involved in gynecological and obstetric care in models was proved to be more effective than traditional teaching
France (CNGOF (Collège national des gynécologues et obstétriciens fran­ without simulation (theoretical learning and mentoring), in improving
çais), CEGO (Collège national des enseignants de gynécologie obstétrique), healthcare students’ pelvic exam technical skills during initial training
CNEGM (Collège National des Enseignants de Gynécologie Médicale), CNSF [1]. When compared to low-fidelity anatomical models and traditional
(Collège national des sages-femmes de France), CMG (Collège de la médecine teaching (theorical learning and mentoring), teaching using professional
générale), FNCGM (Fédération nationale des collèges de gynécologie patients resulted in a higher increase in student confidence, competence,
médicale)), Conseil national professionnel de gynécologie et obstétrique et and communication skills (data from a meta-analysis) [2–4]; however,
gynécologie médicale (CNPGO et GM) and SCGP (Société de chirurgie
gynécologique et pelvienne) decided to develop guidelines for clinical
practice, in close collaboration with healthcare users’ and patients’ as­ Table 1
sociations (CIANE (Collectif interassociatif autour de la naissance) and GRADE (Grading of Recommendations, Assessment, Development, and Evalua­
tion) system for rating level of evidence and guidelines.
ENDOFRANCE (Association française de lutte contre l’endométriose)).
1a. Quality/Level of Evidence (LE) Grades
Methods Quality/level of
evidence (LE)
The objective was to provide national multidisciplinary guidelines High We are very confident that the true effect lies close to that
for the pelvic clinical exam in gynecology and obstetrics. A multidisci­ of the estimate of the effect
plinary experts’ consensus committee of 45 experts was formed (gyne­ Moderate We are moderately confident in the effect estimate
Low Our confidence in the effect estimate is limited
cology, obstetrics and gynecology, general practice, midwifery
Very Low We have very little confidence in the effect estimate
endocrinology and forensic medecine), including representatives of
patients’ associations and users of the health system. 1b. Definition of the strength of the recommendations

The need to perform clinical examination for patients in gynecology STRONG WEAK EXPERT
and obstetrics was specified in 27 pre-defined situations (formulated recommendation recommendation CONSENSUS
(we recommend) (we suggest) (we suggest but
using a PICO (Patients, Intervention, Comparison, Outcome) format)
there is no
based on scientific level of evidence (L.E.). The literature review and evidence)
recommendations were made according to the GRADE® methodology
Positive “It is recommended to “It is recommended to “It is recommended
(see Table 1). The experts’ synthesis work and the application of the do…” do…” to do…”
GRADE method resulted in 27 recommendations. Among the formalized Negative “it is recommended “it is recommended “it is recommended
recommendations, 17 presented a strong agreement, 7 a weak not to perform …” not to perform …” not to perform …”

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for now, professional patients don’t exist in France. Finally, regarding exam?
initial training of healthcare students, simulation training was proved to In postmenopausal women without hormonal treatment, the appli­
be more effective than traditional teaching without simulation, in cation of lidocaine-prilocaine cream 5%, 5 min before the insertion of
improving medical students’ technical and communication skills and is the speculum is associated with less pain during the speculum exami­
interesting to reduce their apprehension of pelvic examination (L.E.: nation [13] (L.E.: VERY LOW) but is associated with burning sensations.
MODERATE). In addition, there is an issue of applicability of this therapeutic option
During initial training, teaching the pelvic exam should include because of its cost (renewal of the consultation, deferred examination,
the use of simulation courses using at least low-fidelity anatomical and absence of reimbursement). There are no studies concerning this
models (STRONG). Concerning life-long continuous training, currently, point in premenopausal women. The quality of the data in the literature
there is insufficient data to make a recommendation. is insufficient to develop a recommendation regarding the relevance of
Question 2 - In a woman requiring a pelvic exam, does making a the use of a local anesthetic to improve the patients’ experience of pelvic
direct inquiry about violence experienced prior to the examination examination.
improve the woman’s experience of gynecological examination in Question 5 – In post-menopausal women requiring a clinical pelvic
comparison with not inquiring about it? exam, is preparative local vaginal estrogen treatment superior to no
Improved knowledge and communication on personal issues and local estrogen treatment before the pelvic exam, in improving women’s
prior experiences of gynecologic examinations may improve the experience (pain, stress, anxiety, comfort) during the pelvic exam?
emotional contact between examiner and patient. The prevalence of No study has evaluated the performance of local estrogen treatment
women reporting a history of violence (sexual, psychological, physical, for the women’s experience during pelvic exam. Therefore, there is
domestic, or extra-domestic) is very high in France and Europe, between insufficient data to make a recommendation.
11 and 15% (up to 48% for psychological violence) [5]. Numerous meta- Question 6 – In a woman requiring a pelvic examination is an
analyses and systematic reviews showed the association between expe­ alternative position superior to the standard gynecological position
rienced violence during childhood and adulthood and psychological (woman placed in dorsal decubitus and feet placed in metal stirrups) in
symptoms such as depression and post-traumatic stress disorder, but improving the woman’s experience during the pelvic exam (pain,
also with symptoms such as pelvic pain, dysmenorrhea, vulvodynia, stress, anxiety, comfort)?
dyspareunia, cycle disorders, endometriosis, symptoms related to There are different possible positions for gynecological examination:
menopause, prematurity and other complications of pregnancy and gynecological position in the supine position or in the semi-sitting po­
suicidal behavior during pregnancy and postpartum, sexually trans­ sition, with feet placed in metal stirrups, gynecological position in the
mitted infections, and cervical cancer [6–8]. History of psychological dorsal decubitus position or in semi-sitting position with feet resting flat
and sexual violence and post-traumatic stress disorder has been shown on the table (“no-stirrups” method, in which the patient is examined
to be associated with increased discomfort during pelvic examination supine with the heel of each foot resting on a corner of the table,
(pain, fear, embarrassment, and anxiety) [9,10]. A study also showed sometimes called the “M” position), lithotomy position with knees fall­
that women who had experienced violence during childhood were at ing apart and heels together at the edge of the table (sometimes called
increased risk of perceiving healthcare to be a violent context [11]. On the “frog” or “diamond” position), lateral position (lying on one side,
the other hand, there is no data describing specific methods to use to hips and knees flexed), etc. In a randomized trial where the position of
carry out pelvic examination that would have demonstrated a significant the feet was not described, out of 143 patients, 49% preferred semi-
improvement in the experience of the examination for women with a sitting position, 34% did not notice any difference, and 17% preferred
history of domestic or sexual violence. the supine position (p < 0.005) [14]. For the examiners, 51% of the
The HAS recommends inquiring about the existence of current or examinations were considered easier and more exhaustive in semi-
past domestic violence, including in the context of gynecological or sitting position, 13% of examinations were easier and more exhaustive
obstetrical consultations. in supine position and there was no difference for 36% of the exami­
Question 3 – In adult women requiring a clinical pelvic exam, is the nations (p < 0.005). Pelvic examination without stirrups was evaluated
use of water-based gel lubrication, superior to no lubrification or other in an American study which included 197 patients randomized into two
lubricant use, in decreasing discomfort (pain, stress, discomfort, groups: 100 patients in the group without stirrups, feet placed on the
anxiety) during pelvic examination? table (intervention group) and 97 in the group with feet placed in metal
The average intensity of experienced pain reported by women stirrups (control group) [15]. Physical discomfort, feelings of vulnera­
(evaluated using a visual analogue scale from 0 to 10) during the ex­ bility and loss of control were measured using a visual analogue scale
amination using a speculum varies, according to the studies, during its (0–100 mm). Patients in the intervention group had their feet placed at
insertion from 1.5 to 5/10, during opening from 3 to 6/10 and during the corners of the table. Patients in the control group had their heels
withdrawal from 2 to 4/10 [12]. A meta-analysis of randomized trials placed in uncovered metal stirrups at a 30-45◦ angle to the examination
concluded that the use of a water-based gel lubricant during a pelvic table. Patients in both groups were supine and draped. VAS scores for
examination with a speculum was associated with lower levels of pain physical discomfort and feelings of vulnerability were both significantly
compared to the use of water [12] (L.E.: HIGH). These results were lower in women examined with flat feet (without stirrups) [15].
confirmed in the various subgroups (menopausal or non-menopausal Although lateral position is used in some countries, it is very rarely used
women, especially). Furthermore, randomized trials have shown that and taught in France. There has been no comparative study to evaluate
the quality of bacteriological, virological and cytological analyses were this position compared to another gynecological position. In conclusion,
not significantly different between the groups with water-based gel standard gynecological position (woman in the supine position, placing
lubricant (without carbomers) and those for which water was used. the feet in metal stirrups) is associated with a poorer experience of the
In adult women requiring a clinical pelvic exam (including for pelvic examination in some women (L.E.: MODERATE).
pap or bacteriological vaginal sampling), using a water-based gel In a woman requiring pelvic examination, it is recommended to
lubrication for the insertion of a speculum is required given its offer an alternative position to the standard gynecological position
association with decreased discomfort (pain, stress, discomfort, (i.e. semi-sitting position, feet resting flat on the table, etc)
anxiety) during pelvic examination. (STRONG). (WEAK), provided this position is compatible with a good quality
Question 4 – In women requiring a clinical pelvic exam, is the exam.
application of preparative local anesthetic vaginal gel superior to no Question 7 - In a woman requiring a pelvic exam, is self-insertion of
local anesthetic preparation before the pelvic exam, in improving the speculum, superior to clinical-based speculum insertion, in
women’s experience (pain, stress, anxiety, comfort) during the pelvic improving women’s experience during the pelvic exam (pain, stress,

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anxiety, comfort)? and pelvic clinical examinations and pelvic ultrasound) was proposed
No study has compared self-insertion of a speculum versus insertion [17]. This algorithm was based on a review of the literature regarding
by the practitioner, but one study observed that among women who the sensitivity and specificity of each useful element for the diagnosis of
agreed to perform self-insertion, this technique was possible and was PID, without being able to highlight any pathognomonic sign [17]. The
associated with women’s satisfaction. Furthermore, women wished, presence of pain on uterine mobilization provides guidance with 95%
when possible, to choose this option for their future examinations (L.E.: sensibility and 74% specificity for PID diagnosis [18]. The presence of an
VERY LOW) [16]. Therefore, it seems possible to offer self-insertion of adnexal mass is also in favor of the diagnosis of PID with moderate
the vaginal speculum to women who wish to. It should be noted that, in diagnostic values. Two studies reported that performing a clinical ex­
published series, a third of the women refused to practice self-insertion. amination in addition to a self-questionnaire did not improve the
Question 8 - In a woman requiring a pelvic exam, is a one-finger sensitivity and specificity of the diagnosis, but this type of self-
vaginal palpation superior to two-fingers vaginal palpation, in questionnaire is not administered in practice. The external validity of
improving the woman’s experience during the pelvic exam (pain, this study has not yet been demonstrated.
stress, anxiety, comfort)? Regarding the diagnosis of adnexal torsion, one study described an
Vaginal palpation using only one finger have been evoked as an effective composite score involving the pelvic physical examination
option for pelvic exam for teenagers but no comparative study assessed (search for metrorrhagia, vaginal discharge and localization of pain),
the two techniques (one or two fingers). anamnesis (medical history) and ultrasound criteria [19].
Question 9 - In a woman requiring a pelvic exam, is the use of Thus, the abdominal and pelvic physical examination, carried out in
relaxation techniques (music, essential-oil diffusion) superior to no addition to the medical interview and ultrasound, improves the diag­
use of relaxation techniques, in improving the woman’s experience nostic management in non-pregnant women consulting at the emer­
during the pelvic exam (pain, stress, anxiety, comfort)? gency department for bleeding or acute pelvic pain, through composite
One trial observed decreased anxiety after pelvic examination car­ predictive scores or models of diagnostic algorithms (L.E.: MODERATE).
ried out in a room in which a diffusion of essential oil of lavender was In a non-pregnant woman consulting for vaginal bleeding or
available, compared to another group for which no diffusion took place. pelvic pain at the emergency department, it is recommended to
However, it is difficult to conclude as to the internal validity of this study carry out a pelvic exam associated with a medical interview and
and as to the transferability and applicability of these results to other ultrasonography (STRONG).
populations. No comparative study has evaluated the isolated perfor­ Question 14: In a non-pregnant woman presenting with vaginal
mance of a relaxing musical ambience on the patient’s experience dur­ discharge and/or vulvar symptoms, is a pelvic exam associated with a
ing a pelvic examination compared to the absence of musical ambience. amedical interview superior to medical interview alone, for the etio­
Question 10: In a woman requiring a pelvic exam, is the sequence logic diagnosis?
‘vaginal palpation before speculum insertion’ superior to the sequence Clinical pelvic examination (vulvar inspection and vaginal and
‘speculum insertion before vaginal palpation’, in improving the wom­ uterine cervix examination under speculum) can modify the etiological
an’s experience during the pelvic exam (pain, stress, anxiety, diagnosis of lower genital tract infections compared to a medical
comfort)? interview alone. Indeed, a retrospective study including 12,073 patients
A study compared the performance of vaginal examination before or presenting with vulvar symptoms (vaginal discharge and/or acute
after insertion of the speculum, without showing any clinically relevant vulvar symptoms), showed that pelvic examination had revealed vaginal
difference, the mean pain scores being very low in both groups (L.E.: or cervical lesions (vesicles, ulcers, or rash) in 25% of cases and that
VERY LOW). The quality of the data in the literature is insufficient to visual inspection under speculum had made it possible to modify the
make a recommendation. diagnosis and/or the management in 11.8% of cases [20]. Performing
Question 11: In a woman requiring a pelvic exam, is the use of a vaginal palpation is not useful for the sole purpose of a positive or
plastic speculum superior to the use of a metallic speculum, in etiological diagnosis of a lower genital tract infection but is useful, as an
improving the woman’s experience during the pelvic exam (pain, addition to the medical interview to rule out an upper genital tract
stress, anxiety, comfort)? infection in the presence of vaginal discharge (L.E.: LOW).
No comparative study has assessed the impact of the material of the In a non-pregnant woman presenting with vaginal discharge and/or
speculum on women’s experience during the examination. This choice vulvar symptoms, it is recommended to carry out a pelvic exam (vulvar
seems to be linked to the habits of professionals and the availability of visual inspection, vaginal and cervix inspection under speculum and
different types of specula at their location of practice. The quality of the vaginal palpation) associated with a medical interview (STRONG).
data in the literature is insufficient to make a recommendation. Question 15: In asymptomatic women consulting for the initiation
Question 12: In a woman requiring a pelvic exam, is the use of a of a hormonal contraception, is a pelvic exam associated with a
sheathed speculum superior to the use of a standard non-sheathed medical interview, superior to a medical interview alone, in identifying
speculum, in improving the women’s experience during the pelvic contraindications and influecing the choice of the type of the hormonal
exam (pain, stress, anxiety, comfort)? contraception?
A randomized trial compared the use of a sheathed plastic speculum No study has compared the direct impact of pelvic examination
versus a conventional plastic speculum of the same dimensions and performed before initiating hormonal contraception. The pelvic clinical
found no difference in pain experienced by women in the two groups, examination does not identify possible contraindications to hormonal
but this endpoint was not the primary endpoint. The data is insufficient contraception (breast cancer, venous and arterial thrombosis, migraine
to make a recommendation. with aura, arterial hypertension, age over 35 and smoking, liver pa­
thologies, etc.) (L.E.: VERY LOW). On the other hand, the medical
Pelvic exam in gynecology interview, blood pressure measurement, weight and height are required
in search of contraindications to combined hormonal contraception.
Question 13: In a non-pregnant woman consulting for vaginal
bleeding or pelvic pain at the emergency department, is a pelvic exam In asymptomatic women consulting for the initiation of a
associated with a medical interview and ultrasonography superior to a hormonal contraception, it is recommended not to perform a
medical interview and ultrasound alone, in improving patients’ systematic pelvic exam (EXPERT CONSENSUS)
management?
Concerning the diagnosis of pelvic inflammatory diseases (PID), a Question 16: In asymptomatic women consulting for the initiation
management algorithm (encompassing a medical interview, abdominal of a contraceptive vaginal diaphragm, is a pelvic exam associated with

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a medical interview superior to a medical interview alone in identifying alone, in diagnosing complications associated with IUD use?
contraindications and influencing the choice of the type of the A prospective cohort study (39,009 patients followed up for 5 years)
diaphragm? showed that a third of uterine perforations occurred after 1 year of IUD
No study assessed the role of pelvic examination in women consul­ use and were diagnosed in half of the cases during a routine pelvic
ting to initiate diaphragm contraception. A pelvic examination permits physical examination [22]. Therefore, these results advocate for an
to verify that the vaginal compliance allows the diaphragm and that annual visual vaginal examination using a speculum, to check the po­
there is no prolapse or vaginal malformation. In addition, a pelvic exam sition of the IUD threads at the external orifice of the uterine cervix.
can help choose the size of the diaphragm (some diaphragms exist in Regarding self-examination by the woman, studies showed a low per­
several sizes). The quality of the available data is insufficient to make a formance of the patients’ self-assessment of the persistence of IUD
recommendation. threads in the cervix. However, self-examination should be offered to
Question 17: In asymptomatic women consulting for the initiation women who do not wish to undergo a clinical pelvic examination. When
of a contraception using an intra-uterine device (IUD), is a apelvic abnormal vaginal discharge is visualized during visual inspection with a
examination associated with medical interview superior to a medical speculum, a vaginal palpation should be carried out in order to search
interview alone, in identifying contraindications and in improving for signs of upper genital tract infection (pelvic inflammatory disease):
women’s experience during the IUD placement? pain on uterine mobilization or an adnexal mass. In conclusion, a pelvic
Some contraindications to the insertion of an IUD can be detected by clinical examination associated with a medical interview seems superior
clinical examination (uterine malformation, pelvic inflammatory dis­ to a medical interview alone, in diagnosing for complications associated
ease, cervical cancer). Carrying out examination prior to insertion could with IUD use in asymptomatic women (L.E.: MODERATE).
therefore make it possible to immediately direct the practitioner to­ In asymptomatic women consulting after intra-uterine device
wards another contraceptive choice. There is no study that has evaluated (IUD) insertion, it is recommended to carry out, in the year
the performance of pelvic examination versus history alone in screening following the insertion and then regularly, a pelvic examination
for genital malformations and diagnosing uterine retroversion. Howev­ associated with a medical interview, including visual inspection
er, pelvic clinical examination prior to insertion of an IUD enables to using a speculum to check the position of the IUD threads
detect vaginal pain on examination which could direct the practitioner (STRONG).
towards another contraceptive choice, if possible. In young nulliparous Question 21: In asymptomatic non-pregnant women consulting for
women, pelvic examination prior to insertion of an IUD is associated gynecological check-up, is a pelvic exam associated with a medical
with better satisfaction of women during this procedure, compared to interview superior to a medical interview alone in screening for sexu­
the absence of prior pelvic examination (L.E.: LOW) [21]. There is no ally transmitted infections?
similar study in women who have already given birth. Visual inspection of the vulva and the vagina can diagnose genital
In asymptomatic women consulting for the initiation of a warts, but the performance of this visual examination has not been
contraception using an intra-uterine device (IUD), it is recom­ evaluated. The performance of vaginal palpation (search for pain) and
mended to carry out a pelvic examination (vaginal palpation and visual inspection of the cervix using a speculum (search for colpitis or
visual vaginal inspection using a speculum) before the placement cervicitis) seemed poor for sexually transmitted infections screening in
of the IUD, since it may diagnose some contraindications or a ret­ asymptomatic women (L.E.: VERY LOW) [23].
roverted uterus and due to its association with improved patient Regarding the performance of pelvic clinical examination with the
experience in young nulliparous women during the IUD placement aim of screening for sexually transmitted infections in asymptomatic
(WEAK). women, the current data is insufficient to make a recommendation.
Question 18: In asymptomatic women consulting for follow-up after Question 22: In non-pregnant women consulting for gynecological
prescription of a hormonal contraception, Is a pelvic exam associated check-up (general population), is a pelvic exam associated with
with a medical interview superior to a medical interview alone, in clinician-collected cervico-vaginal sampling, more effective than
screening for potential associated complications? vaginal self-sampling in screening for sexually transmitted infections?
No study evaluated the performance of the pelvic clinical ex­ Clinician-collected cervico-vaginal sampling is not more effective
amination associated with an interview compared to an interview than vaginal self-sampling in screening for Chlamydia trachomatis &
alone in screening for complications associated with hormonal Neisseria gonorrhoeae infections (L.E.: HIGH) [24]. Vaginal self-sampling
contraception in asymptomatic women. Clinical pelvic examina­ is associated with a higher diagnostic efficiency when compared to
tion cannot detect the main complications of hormonal contra­ urinary self-sampling, in screening for sexually transmitted infections.
ception (hyperglycemia, dyslipidemia, thromboembolism) (L.E.: In non-pregnant asymptomatic women, for the purpose of
VERY LOW). screening for sexually transmitted infections (Chlamydia tracho­
In asymptomatic women consulting for follow-up after pre­ matis & Neisseria gonorrhoeae), it is mandatory to perform either a
scription of a hormonal contraception, it is recommended not to vaginal self-sampling or a clinical-collected cervico-vaginal sampling
perform a systematic clinical exam for the sole purpose of (using a speculum). (STRONG). Urinary self-sampling is not rec­
screening for associated complications (EXPERT CONSENSUS). ommended for the screening for sexually transmitted infections.
Question 19: In asymptomatic women consulting for a gynecolog­ Question 23: In non-pregnant women consulting for gynecological
ical visit/follow-up and who use a contraceptive vaginal diaphragm, is check-up (general population), is a pelvic exam associated with a
a pelvic exam associated with a medical interview superior to a med­ medical interview and cervical sampling, more effective than a medical
ical interview alone in diagnosing complications associated with a interview associated with self-sampling in screening for cervical
diaphragm? cancer?
Complications associated with contraception using a diaphragm/ The performance of an HPV-HR-PCR test carried out by a clinician
cervical cap/vaginal cup, are repeated urinary tract infections and, during a pelvic examination using a speculum, is equivalent to that of
exceptionally, septic shock. No study has evaluated the performance of self-sampling for cervical cancer screening (L.E.: HIGH). However, due
pelvic examination in the follow-up of asymptomatic women who use a to the organization of cervical cancer screening in France, when the
contraceptive vaginal diaphragm. Therefore, there is insufficient data to HPV-HR-PCR test is positive (presence of HPV-HR-PCR), a “reflex”
make a recommendation. cytological test is carried out for triage of high-risk women (possible
Question 20: In asymptomatic women attending a follow-up visit indication for colposcopy) which is not feasible in France on self-
after intra-uterine device (IUD) insertion, is a pelvic examination samples. HPV vaginal self-sampling is highly useful (good diagnostic
associated with a medical interview superior to a medical interview efficiency) in vulnerable populations and is associated with improved

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screening in under screened populations. Question 27: In a woman consulting for urinary incontinence, is
In non-pregnant women aged 25 to 65 y/o, consulting for gy­ pelvic examination superior to medical interview alone, in improving
necological check-up (general population), a clinical pelvic exam the effectiveness of patient management?
associated with a clinician-collected uterine cervix sampling is The diagnosis of the type of urinary incontinence is based on the
recommended (repeated after 3 or 5 years according to age range) medical interview. However, carrying out a clinical examination (vul­
for cytological analysis or HPV-HR-PCR test, for the screening of vovaginal atrophy, cervico-urethral mobility, cough stress test, Valsalva
cervical cancer (STRONG). In women who escaped national screening, maneuver…) is useful to identify risk factors for treatment failure, and to
it is mandatory to offer vaginal self-sampling for HPV-HR-PCR test. guide patient management and patient information regarding available
Question 24: In non-pregnant asymptomatic women consulting for treatments. Urethral mobility assessment and associated urethral sup­
gynecological check-up (general population, with no personal or port maneuvers (“Ulmsten”, “TVT” and “Bonney” maneuvers) also seem
family history of cancer), is a pelvic exam associated with a medical to be associated with higher success rates following mi-urethral sling
interview, more effective than a medical interview alone in screening procedures [31] (L.E.: LOW).
for uterine, ovarian or endomectrial cancer? In a woman consulting for urinary incontinence, it is recom­
Regarding screening of endometrial cancer, no study assessed the mended to perform a clinical exam to improve the quality of pa­
efficacy of pelvic exam as a screening tool in asymptomatic women. For tient management and information regarding the success rates
women in the general population (with no personal or family history of associated with available treatments (WEAK).
gynecological cancer), a study showed very low sensibility of an annual Question 28: In a woman consulting for vaginal bulge (suspicion
bimanual ovarian palpation (coupled with CA125 test and transvaginal of pelvic organ prolapse), is pelvic examination superior to medical
ultrasound) as a screening test for ovarian cancer in asymptomatic interview alone, in guiding diagnostic strategy and patient
women [25] (L.E.: HIGH). management?
In non-pregnant asymptomatic women consulting for gyneco­ Clinical examination is the gold standard for the diagnosis of pelvic-
logical check-up (general population, with no personal or family organ prolapse, enabling assessment and quantification of the prolapse.
history of cancer), it is recommended not to perform a systematic The clinical exam clearly distinguishes the different stages of the pelvic
pelvic exam for the purpose of screening for ovarian malignancy organ prolapse. Regarding the possible association between the type of
(STRONG). symptoms and the type of pelvic organ prolapse, several studies have
Question 25: In non-pregnant asymptomatic women consulting for shown significant associations between bladder outlet obstruction
gynecological check-up (general population, with no personal or symptoms and cystocele or between obstructed defecatory symptoms
family history of breast/gynecological cancer), is rapid pelvic sonog­ and rectocele, but these correlations were only weak to moderate (r
raphy used as a screening tool more effective than clinical examination between 0.2 and 0,5) [32,33]. Thus, the symptoms associated with
in screening for uterine, ovarian or endometrial cancer and in prolapse (ideally assessed using a validated questionnaire) are insuffi­
improving the prognosis of these malignant diseases? ciently associated with a positive diagnosis of genital prolapse (type and
In non-pregnant asymptomatic women (general population, with no stage), to waive the need for pelvic physical examination. In other
history of breast/gynecological cancer), studies showed that the per­ words, symptoms associated with pelvic organ prolapse are unspecific
formance of rapid pelvic sonography is higher than that of pelvic exam and cannot precisely identify the type and stage of the prolapse (L.E.:
in screening for ovarian and endometrial carcinomas, but is not asso­ MODERATE). Furthermore, pelvic physical examination is useful in
ciated with an increase in survival rates; moreover, the cost/benefit ratio identifying certain differential diagnoses: rectal prolapse, pelvic varices,
is unfavorable. (L.E. MODERATE) [26–29]. hemorrhoids, vulvar tumor, etc.
In non-pregnant asymptomatic women consulting for gyneco­ In a woman consulting for vaginal bulge (suspicion of pelvic
logical check-up (general population, with no personal or family organ prolapse), it is recommended to perform a clinical exam in
history of breast/gynecological cancer), it is recommended not to order to improve the accuracy of the diagnosis and the quality of
perform a systematic rapid pelvic sonography used as a screening patient management (STRONG).
tool for uterine, ovarian or endometrial cancer and for the purpose Question 29: In a woman consulting for chronic pelvic or perineal
of improving prognosis of these malignant diseases (WEAK). pain, is pelvic examination superior to medical interview alone, in
Question 26: In non-pregnant asymptomatic women consulting for guiding the diagnostic strategy?
gynecological or pregnancy check-up (general population, with no Pelvic examination of patients with chronic pelvic or perineal pain,
personal or family history of breast cancer), is a clinical breast ex­ aims to identify the cause(s) of pain. In a woman consulting for chronic
amination associated with a medical interview more effective than a pelvic or perineal pain, a pelvic physical examination (inspection of the
medical interview alone, in improving the sensitivity of breast cancer vulva, search for allodynia, vaginal examination in search of a myofas­
screening? cial syndrome) is superior to a medical interview alone in identifying the
In women participating in organized screening after 40 years of age, etiology of the pain and this can modify the patient’s management (L.E.:
clinical examination allows for the detection of at least 5% more cancers LOW).
compared to screening by mammography alone (L.E.: MODERATE) In a woman consulting for chronic pelvic or perineal pain, it is
[30]. Data from low- and middle-income countries where mammog­ recommended to perform a clinical exam for the diagnosis of
raphy is not accessible, have shown a reduction in stage at diagnosis vulvar disease, myofascial pain syndrome and/or vulvar or peri­
when women benefit from a clinical breast exam in screening programs. neal allodynia (WEAK).
In non-pregnant asymptomatic women over 40 y/o consulting Question 30: In a woman consulting for suspicion of endometriosis,
for gynecological check-up (general population, with no personal is pelvic examination superior to medical interview alone, for the
or family history of breast cancer), it is recommended to system­ diagnostic strategy?
atically perform a clinical breast examination to improve the sen­ Medical interviewing has good sensitivity for the diagnosis of
sibility of breast cancer screening (STRONG). endometriosis, but lacks specificity, and the published questionnaires
Concerning clinical breast examination in women under 40 y/o as have yet to have an external validation on an independent cohort, which
part of the breast cancer screening strategy, currently, there is insuffi­ therefore limits their use. Clinical examination has a low sensitivity for
cient data to make a recommendation. However, the H.A.S. recommends the diagnosis of endometriosis: a normal clinical examination does not
systematic clinical breast examination as a screening tool in women of eliminate the diagnosis (more than 50% of patients with endometriosis
any age, during consultations for pregnancy or contraception prescrip­ diagnosed by laparoscopy have a normal clinical examination). How­
tion or follow-up, and annually for all women over 25 y/o. ever, a “positive” clinical examination, i.e. identifying an element in

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favor of the diagnosis of endometriosis, is very relevant with a strong of pelvic physical examination was evaluated in a Danish retrospective
positive predictive value (significant added value of the pelvic exami­ cohort study that included 161 patients diagnosed with a malignant
nation). This relevance of the clinical examination is equivalent to that pathology (ovarian cancer (n = 63), endometrial cancer (n = 50), cancer
of ultrasound (except for the diagnosis of endometrioma) [34]. One of cervical cancer (n = 34) or vulvar cancer (n = 14)) by their general
the benefits of clinical examination is also to assess the painful nature of practitioner [37]. This study identified 17% of delayed (late) diagnoses
possibly palpated lesions to judge their attributing responsibility and to (defined as more than 90 days) with a significant increase of the delay in
identify any associated myofascial syndrome which will require specific the diagnosis of malignant gynecological pathologies in patients who
algological management [35]. Regarding the value of MRI, no study has consulted their general practitioner with “warning signs” (including
evaluated the sensitivity and specificity of pelvic MRI for the diagnosis abnormal bleeding) when the gynecological examination had not been
of endometriosis, without prior clinical examination. Thus, pelvic ex­ carried out (OR 5,36 (1,05––27,44) p = 0,044) [37]. Thus, clinical
amination (examination under speculum and vaginal examination) pelvic examination seems to be associated with a significant reduction of
associated with a medical interview improves the diagnostic manage­ the time to diagnosis of malignant gynecological pathologies, compared
ment compared to a medical interview alone (L.E.: MODERATE). to medical interview alone. (L.E.: LOW).
In a woman consulting for suspicion of endometriosis, it is In a woman (postmenopausal or non-pregnant premenopausal)
recommended to perform a clinical exam to confirm the diagnosis presenting with abnormal gynecological bleeding, it is recom­
and to guide imaging prescription (STRONG). Concerning rectal ex­ mended to carry out a medical interview and a pelvic examination
amination in the field of the diagnostic strategy for endometriosis, there in order to establish the etiological diagnosis and to prescribe im­
is currently insufficient data to make a recommendation. aging (STRONG).
Question 31: In a woman consulting for infertility, is pelvic ex­
amination superior to medical interview alone, in diagnosing Pelvic exam in pregnant women and post-partum
infertility?
Infertility is mostly a multifactorial condition, and the diagnosis of its Question 34: In asymptomatic pregnant women with no risk factor
etiology requires multiple clinical and paraclinical explorations (hor­ for premature delivery consulting for check-up, is a pelvic exam more
monology, bacteriology, imaging, etc). The clinical examination may effective than a medical interview alone, in decreasing pregnancy
reveal signs of pelvic inflammatory disease, genital malformation, complications rates (pregnancy loss, premature delivery, infection,
endometriosis or uterine myomas. Published studies suggest that a etc).
pelvic exam associated with a medical interview is more effective than a The results of a meta-analysis that included 2 randomized trials
medical interview alone concerning the diagnosis of etiologies of (7163 asymptomatic women) did not show any modification of the risk
infertility (L.E.: VERY LOW). of preterm delivery (<37 WA) associated with a regular practice of
In a woman consulting for infertility, it is recommended to vaginal examination (women examined throughout pregnancy vs.
perform a clinical exam for the etiological diagnosis (endometri­ women not examined) (OR = 1.05 [95% CI 0.85–––1.31]) [38]. In
osis, uterine myoma, adnexal mass, genital malformation) (WEAK). addition, literature suggests that, in asymptomatic women with no risk
Question 32: In a woman consulting for a pelvic or abdominal mass, factor for preterm delivery consulting for check-up during pregnancy,
is pelvic examination superior to medical interview alone, for the the practice of systematic vaginal examination is not associated with a
diagnosis or for the guidance of the imaging prescription? reduction of the risk of preterm delivery compared to check-up without
For a woman consulting for a pelvic mass, the objective of the pelvic vaginal examination, nor with a reduction of other complications
physical examination is to specify the characteristics of the lesion and in (mother-fetal infection and loss of pregnancy) (L.E.: MODERATE).
particular, its size, etiology (uterine or adnexal), potential presence of In asymptomatic pregnant women with no risk factor for pre­
concomitant associated lesions (aspect of the uterine cervix, pelvic mature delivery consulting for pregnancy check-up, it is recom­
infiltration on vaginal examination, mobility of the mass, presence of mended not to perform systematic vaginal examinations since it is
ascites or nodules of carcinomatosis). The prevalence of the different not associated with a decrease in pregnancy complications
types of pelvic masses (uterine, adnexal) depends on the age of the pa­ (STRONG).
tients. The first cause of abdominopelvic mass to be eliminated in Question 35: In asymptomatic pregnant women with no history of
women of childbearing age is evolutive pregnancy. There is little data premature delivery, is the measurement of cervical length by system­
concerning the precise diagnostic value of vaginal examination in this atic transvaginal ultrasound associated with a decrease in complica­
context, but it is in favor of a positive contribution of this pelvic physical tion rates (premature delivery rate, fetal loss, infection, etc) compared
examination to the management of women. A cohort study showed that to check-up without systematic cervical length measurement by
a pelvic examination (vaginal examination) performed by an experi­ ultrasonography?
enced practitioner“ was able to distinguish a uterine mass from an It has been clearly proven that a short cervix (measured by vaginal
adnexal mass with a good ability to detect adnexal masses.(LR de 4.13) ultrasonography) is associated with an increased risk of spontaneous
[36]. A pelvic examination combined with a medical interview appears preterm delivery. When the length of the cervix is ≤ 15 mm at about 23
to be superior to a medical interview alone, as it can help to distinguish WG, the risk of spontaneous preterm delivery ≤ 32 WG is about 50%
an adnexal mass from a uterine mass (L.E.: VERY LOW). [39]. However, given the low prevalence of prematurity, the low posi­
tive predictive value and the high rate of false negatives, worldwide
In a woman consulting for a pelvic or abdominal mass, it is scientific societies do not recommend a systematic measurement of
recommended to perform a clinical exam (STRONG) cervical length in asymptomatic women with no previous premature
delivery. Cerclage, pessary, and intramuscular progesterone have not
Question 33: In a woman (postmenopausal or non-pregnant pre­ shown a reduction of preterm delivery rates in asymptomatic women
menopausal) presenting with abnormal gynecological bleeding, is pel­ with a short cervix. Only vaginal progesterone has shown efficacy in
vic examination superior to medical interview alone, for the diagnosis reducing the risk of preterm delivery in asymptomatic women with a
or for the guidance of imaging prescription? short cervix identified by cervical ultrasound in two randomized
No randomized trial has compared a medical interview alone against controlled trials. Thus, the measurement of cervical length by systematic
a physical pelvic examination associated with a medical interview in this vaginal ultrasound is not associated with a reduction in prematurity
situation. The usefulness of vulvar, vaginal and uterine cervix exami­ compared to check-up without a systematic cervical length measure­
nation under speculum is unquestionable. The role of vaginal palpation ment by ultrasonography (L.E.: MODERATE).
was not evaluated except in the context of emergency bleeding. The role In asymptomatic pregnant women with no prior history of

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premature delivery, it is not recommended to perform measure­ examination superior to a medical interview and ultrasonography, in
ment of cervical length by a systematic transvaginal ultrasound diagnosing a premature rupture of membranes (PROM)?
during pregnancy check-up (STRONG). The gold standard for the diagnosis of PROM is clinical visual in­
Question 36: In a pregnant woman consulting for vaginal bleeding spection using a sterile speculum. In the event of the visualization of an
or abdominal pain during the 1st trimester of pregnancy, is a pelvic abundant flow of clear fluid in the vagina, no additional test is required.
examination added to a medical interview and pelvic ultrasonography No study has evaluated the performance of vaginal palpation for the
superior to a medical interview associated to ultrasonography alone diagnosis of PROM. The combination of vaginal palpation and visual
for the patient’ management? inspection under speculum is associated with a shorter latency to de­
In the first trimester, the diagnostic performance of the pelvic ex­ livery compared to visual inspection under speculum alone (average
amination depends on the suspected diagnosis (miscarriage, ectopic difference of 4.5 days against vaginal examination) (LE: LOW).
pregnancy, etc). When there is a suspicion of miscarriage, the pelvic In a woman during the 2nd or 3rd trimester of pregnancy
examination with vaginal inspection using a speculum improves the consulting for a suspicion of amniotic fluid loss, it is recommended
performance of the diagnosis, since this visual examination enables the to carry out a clinical visual inspection using a speculum, for the
assessment of the amount (severity) of the bleeding/hemorrhage and the diagnosis of a premature rupture of membranes (STRONG); how­
search for the presence of trophoblastic tissue within the uterine cervix ever, it is recommended not to perform a systematic vaginal
or the vagina. When the suspected diagnosis is an ectopic pregnancy, palpation (STRONG).
vaginal examination is useful while ultrasound is not helpful. Indeed, for Question 40: In an asymptomatic woman consulting 6–8 weeks
the diagnosis of ectopic pregnancy, several studies observed that the after delivery, is a pelvic examination superior to a medical interview
abdominal and pelvic physical examination was inferior to ultrasound alone, in reducing the prevalence of long-term pelvic disorders?
and a meta-analysis demonstrated a better diagnostic performance of There is no comparative data regarding the contribution of pelvic
ultrasound (Se = 88%, Sp = 99% with LR+ = 111 and LR- = 0.12) physical examination compared to medical interview alone when car­
compared to pelvic examination [40]. However, ultrasound examina­ ried out at 6–8 weeks postpartum, in asymptomatic women. The clinical
tion is not available in all healthcare clinics (general practitioners for examination allows for the diagnosis of levator ani avulsion and
example). The pelvic examination also contributes to the diagnosis of asymptomatic pelvic organ prolapse. However, no prevention strategy
tubal rupture, in addition to ultrasound (L.E.: LOW). and no treatment has shown any capacity to reduce the prevalence of
In a pregnant woman consulting for vaginal bleeding or long-term pelvic disorders, when the patient is asymptomatic at the
abdominal pain during the 1st trimester of pregnancy, it is rec­ post-partum period (L.E.: VERY LOW).
ommended to carry out a vaginal visual inspection using a specu­ In an asymptomatic woman consulting 6–8 weeks after delivery, it
lum (WEAK). It is recommended to perform an additional vaginal is recommended not to perform a systematic pelvic exam, for the
palpation when pelvic ultrasonography is not available or when sole purpose of preventing long-term pelvic disorders (EXPERT
ultrasonographic findings are non-informative. CONSENSUS).
Question 37: In a woman consulting for vaginal bleeding during the
2nd or 3rd trimester of pregnancy, is a pelvic examination associated Discussion
to a medical interview and ultrasonography, superior to a medical
interview and ultrasonography alone, in reducing the risk of These recommendations, even of “strong” grade, should not be
complications? applied blindly. A “recommended” examination is only offered/pro­
No study has evaluated the contribution or the performance of pelvic posed to the woman who will choose whether to comply with it, after the
examination in women presenting with vaginal bleeding in the 2nd or explanations by the health professional regarding the purpose of this
3rd trimester of pregnancy. In addition, vaginal palpation is usually not examination.
recommended when placenta praevia is suspected. Vaginal visual in­ Clinical common sense must prevail to adapt these recommendations
spection using a speculum enables to search for a cervical abnormality to each patient, to each consultation and be adjusted to the setting of the
(L.E.: VERY LOW). consultation.
Concerning clinical pelvic examination with regards to the man­ Recommendations with an “expert consensus” have been kept to a
agement of vaginal bleeding during 2nd or 3rd trimester of pregnancy, strict minimum. They were based on an agreement by at least 70% of the
there is currently insufficient data to make a recommendation. working group. Regarding screening for a history of violence before
Question 38: In a woman during the 2nd or 3rd trimester of preg­ pelvic examination, consensus could not be reached by the working
nancy consulting for abdominal pain, is a pelvic examination superior group due to the lack of research regarding the impact of such screening
to a medical interview and uterine cervical length ultrasonographic in this context. Its implementation would require a complex reflection
measurement, in reducing the risk of complications? regarding its frequency and its validity in women consulting for an
Uterine cervical length measurement by vaginal ultrasound is the emergency or in women who require to have several iterative exami­
best exam to guide the treatment of a premature delivery threat. How­ nations, for example during pregnancy or during childbirth/delivery.
ever, all the studies that evaluated the measurement of cervical length However, the working group consensually wished to remind the readers
by pelvic ultrasound excluded women with a cervix dilated more than 3 of the H.A.S. recommendations on the screening/identification of do­
cm at clinical examination [41]. To eliminate an imminent delivery, it is mestic violence, despite the absence of any recommendation on the
necessary to perform a visual vaginal inspection using a speculum or a specific identification of a history of sexual violence in adult women.
vaginal palpation. In addition, studies suggest that ultrasound mea­
surement of the cervical length associated with vaginal examination is Declaration of Competing Interest
superior to ultrasound cervix measurement alone [42,43] (L.E.:
MODERATE). The authors declare the following financial interests/personal re­
In a woman during the 2nd or 3rd trimester of pregnancy lationships which may be considered as potential competing interests:
consulting for abdominal pain, it is recommended to carry out a AF: SELAS Pointgyn, Laboratoire Innotech International, Respiratory and
clinical pelvic examination (vaginal visual inspection using a Women’s Health Products, Center for observational and real-world evidence
speculum and/or vaginal palpation) in order to exclude an immi­ (CORE); CLR: Ferring; CRJ:Bayer, Bristol Myers Squibb, Merck Serono
nent delivery (STRONG). Healthcare, Mylan, Roche, Theramex; ES: Evalformsanté; HB: Organon,
Question 39: In a woman during the 2nd or 3rd trimester of preg­ Bayer, Gédéon Richter, MSD vaccins, Exeltix, Besins; LMM: Ferring, Vichy,
nancy consulting for a suspicion of amniotic fluid loss, is pelvic Ipsen, Evalformsanté, Besins, Gédéon Richter, Effik, Theramex; MB: Gédéon

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