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#3 Subclinical Hypothyroidism / Routine Bimanual Exams
61 Plays2 years ago
Levothyroxine is one of the most commonly prescribed medications in the US, and nearly two thirds of these patients don't actually need to be taking it! In this episode, Drs. Bobby Scott and Sandy Robertson review the evidence to find out which patients, if any, with subclinical hypothyroidism should be treated.
Also, Dr. Dawn Caviness interviews our first guest, Cabarrus Family Medicine Chief Resident, Dr. Macy Osborn as she tells us whether we should be doing routine bimanual exams.
CORRECTION: At 05:49, it should be noted that overt hypothyroidism is where TSH is high and T4 is low, rather than both values being low as was mistakenly stated in the recording.
Episode outline:
- How many patients take levothyroxine for subclinical hypothyroidism? 03:35
- Rationale behind treating these patients 07:18
- Evidence surrounding treatment of subclinical hypothyroidism 09:10
- Potential harms of treatment 16:20
- The bottom line: when do we treat patients with subclinical hypothyroidism? 17:27
- Should we be doing routine bimanual exams? 21:53
Links from this episode:
- Subclinical hypothyroidism and CV risk: https://pubmed.ncbi.nlm.nih.gov/20858880/
- Levothyroxine does not improve quality of life and thyroid-related symptoms in SCH: https://pubmed.ncbi.nlm.nih.gov/30285179/
- BMJ guideline on treatment of SCH: https://pubmed.ncbi.nlm.nih.gov/31088853/
- Does SCH add any symptoms?: https://pubmed.ncbi.nlm.nih.gov/33872585/
- Levothyroxine does not improve symptoms in older adults with SCH: https://pubmed.ncbi.nlm.nih.gov/32365355/
- Levothyroxine does not improve symptoms in adults aged 80+ with SCH: https://pubmed.ncbi.nlm.nih.gov/31664429/
If you liked the episode, please leave a positive review and subscribe! Tell your colleagues and friends!
Comments/Questions/Suggestions? Email us at whatstheproofpodcast@gmail.com or find us on Twitter @theproofpodcast!
Credits:
- Hosts: Bobby Scott, MD, FAAFP; Sandy Robertson, PharmD; Dawn Caviness, MD, BSN
- Production & Cover Art: Bobby Scott, MD, FAAFP
- Music: Twisterium, MondayHopes, Muzaproduction, and SergeQuadrado from Pixabay
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Transcript
Introduction to Evidence-Based Decision-Making
00:00:00
Speaker
You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
00:00:35
Speaker
Welcome, everybody, to the What's The Proof podcast. I'm Bobby Scott. And with me, as usual, is Sandy Robertson. Sandy, how are you? I'm doing great this morning. How are you, Bobby? Oh, I'm doing
Subclinical Hypothyroidism: Controversial Simplicity?
00:00:47
Speaker
wonderful. I'm excited to talk about today's topic of subclinical hypothyroidism. Sounds very controversial.
00:00:57
Speaker
It's a little bit. Yeah, for sure. Leave it to us to make the easiest thing controversial, right? Yeah, people are probably going to be angry and say, this was supposed to be easy. I never even think about this, but now I'm going to have to because you guys ruined it. I know. It kind of gives me pleasure. Yeah.
00:01:17
Speaker
Anyway, well, I last time I really wanted to recognize you, Sandy, and give you a shout out because in the January, 2022 issue of American Family Physician, you had an article published.
00:01:35
Speaker
I did. You don't have to bring it up. Well, I want to. So tell us a little bit about the article because it was wonderful. Sure. This was a very easy editorial, not really, about all the new glucose lowering agents and the benefits of cardiovascular disease.
00:01:57
Speaker
And I will tell you that the best part of that article was when it was finished. I was really ready to stop thinking about diabetes for a week or two. It's complicated, as you know, so many medications, so much data. It was a tough one. So I appreciate the accolades.
Diabetes Medications: Evolving Complexities
00:02:16
Speaker
Yeah, no, you deserve them. It is complicated. I think we're all getting used to this idea of that you got to consider other factors when you start diabetes medications now. And it's not just algorithmic metformin, then whatever after that.
00:02:35
Speaker
It's not, it's changing. The residents hear me over and over again, and that's good and bad, but I'm hoping by the time they graduate they'll just have it memorized in their armamentarium of how to best prescribe these expensive meds and when not to. Yeah, and then about five, ten years they'll have to forget it all and figure out something else new that's come out.
00:02:58
Speaker
I cannot wait for the day when I can say, Victor's is generic. Jordyann's is generic. But you shouldn't use them because there's this new one that's out that's even better than those. Maybe I'll be retired by then. I want to put that on you, Bobby. All right. Well, I look forward to that. But yeah, I think it's a great topic and maybe it's someone we'll talk about on this podcast sometime.
00:03:24
Speaker
I would be ready. If you out there listeners want to hear about that, just shoot us an email and let us know. We'll consider it. I have a draft ready.
Levothyroxine Prescriptions vs. Hypothyroidism Cases
00:03:35
Speaker
All right. Well, like we said, today's topic is subclinical hypothyroidism.
00:03:42
Speaker
Sounds like this is a pretty common problem if we're going to discuss it, yes? Oh, indeed. Why don't you get us started? I will. I don't think anybody's going to be shocked when I say that it's estimated that over 7% of the US population, which is 23 million, have an active prescription for levothyroxine, which of course is a synthetic form of thyroxine, which is our endogenous hormones secreted by the thyroid gland.
00:04:11
Speaker
Our treatment with levothyroxine is traditionally aimed at replacing a deficiency in endogenous thyroxine, which I'm just going to call T4. And that condition is called overt hypothyroidism. And we know that that can lead to severe complications when untreated.
00:04:29
Speaker
Now, survey studies and large prevalence studies such as NHANES-3 have suggested that between 0.1 and 2% of the U.S. population have overt hypothyroidism. Now, keep in mind, I just said, 7% of the U.S. population have an active prescription for levothyroxine.
00:04:45
Speaker
That's a big difference. Why are all these people taking levothyroxine? I'm glad you asked, Bobby, because those numbers do not add up, do they? So why are they taking it? We can look at some of the data. A retrospective cohort study published in June of 21 showed that between 08 and 2018, 60% of patients newly started on levothyroxine were being treated for what we call subclinical hypothyroidism.
00:05:14
Speaker
Now this is where T4 levels are measured as normal. So T4 is normal, but your TSH levels are high. We know that TSH is made by the pituitary gland. It's meant to signal the thyroid gland to make more T4 and T3. We also know all about the feedback mechanism.
00:05:34
Speaker
So when T4 and T3 are low, the pituitary releases more TSH to stimulate more production of T4 and T3, and then vice versa. When the levels are high, TSH goes down in response, right?
00:05:47
Speaker
Yeah, so to be clear, overt hypothyroidism is where both TSH and T4 are low. Correct. Subclinical hypothyroidism is when TSH is high, but T4 levels are normal. And there has been consensus that you should treat overt hypothyroidism with thyroid hormone replacement since the three to four decades after George Murray's 1892 paper
00:06:14
Speaker
which demonstrated the dramatic benefits of using a sheep thyroid extract to treat patients with myxedema, which is a manifestation of severe hypothyroidism. Now, of course, we are very data-minded on this podcast. Yes, we are. Interestingly, randomized controlled trials showing outcome benefits of treating hypothyroidism are either incredibly difficult to find or they just don't exist.
00:06:40
Speaker
I know. Who would have thought? Yeah. It's not surprising, though, that this is a practice that became standard of care before the advent of the randomized controlled trial. I don't know that anyone is ever going to do such a trial and nor am I suggesting that it's needed, but I just find it interesting.
00:06:57
Speaker
It's probably an instance where a hundred years of clinical experience and some dramatic case reports are probably enough, even if we can't have definitive proof. But if some bold researcher out there wants to go test it in an RCT, then they've got my full support.
00:07:13
Speaker
Absolutely. I'll be happy to help recruit patients.
Treating Subclinical Hypothyroidism: Why and Why Not?
00:07:17
Speaker
Now, Bobby, it is surprising to me that so many patients on levothyroxine are taking it for subclinical hypothyroidism. The word subclinical indicates that the patient has no symptoms, right?
00:07:29
Speaker
Yeah, I would guess that when it comes to prescriptions from primary care providers like me, it's because symptoms are being attributed to this condition, even though the definition implicates that the patient should not have symptoms. I think it's very likely that a sizable majority of these patients were started on levothyroxine by their PCP, as it's
00:07:51
Speaker
not really a frequently referred condition. No, it's not. But when it comes to prescriptions from endocrinologists, I assume that most endocrinologists are following the AAC American Thyroid Association guidelines that were published in 2012, which recommend considering treatment based on TSH levels.
00:08:12
Speaker
So if the TSH is slightly elevated in the 4.5 to 10 milliunits per liter range, they stated it's uncertain which patients will benefit, but there is consensus in the guideline that patients with a TSH greater than 10 should be treated.
00:08:29
Speaker
And this is mainly because large cohort studies indicate that a TSH greater than 10 in patients with subclinical hypothyroidism has been associated with an increased risk of cardiovascular events and cardiovascular mortality, although not overall mortality.
00:08:50
Speaker
Now, there are some flaws in this data, which we'll circle back to later, but I do think a large portion of patients with subclinical hypothyroidism are being treated out of an attempt to alleviate one or more symptoms. I would agree with that. Yeah, so we understand the reasoning behind the decision to treat, but the question that we're going to ask is whether any of this is actually supported by the evidence.
00:09:16
Speaker
We would be remiss if we didn't ask that question. So the short answer is no. So let's start with a scenario of treating subclinical hypothyroidism to manage symptoms. Some of the most common symptoms that are attributed to subclinical hypothyroidism are dry skin, fatigue, and constipation.
00:09:36
Speaker
Now, these are all very common symptoms throughout the general population with many possible etiologies. You check some labs and their TSH is a bit high, so now you have a lab abnormality to go along with some symptoms, so you put them only with oroxine and call it a day, right? What a great doctor you are.
00:09:56
Speaker
Well, a recent population-based study published last December found no difference between symptoms in the subclinical hypothyroidism group and the general population. A shocker there, right? There were 8,900 patients who completed a symptom questionnaire and had baseline thyroid function testing.
00:10:17
Speaker
These symptoms of fatigue and dry skin were commonly reported in both groups, but in half of the patients, another comorbidity could explain their symptoms.
00:10:28
Speaker
So this cross-sectional study suggests that people with subclinical hypothyroidism don't really have an increase in symptoms compared to the general population. But what if the study is wrong? Because some people seem to get better on treatment. Right. You're exactly right. And this is complicated.
00:10:47
Speaker
I am not being facetious when I say placebo effect is a very real thing. It's been shown in RCTs, even when the patient knows that they're taking placebo, their symptoms get better. Okay, so let's not, you know, be remiss of that. Unfortunately, in the last few years, we've had some moderate quality evidence that has shown that most patients should not be treated.
00:11:13
Speaker
The best data comes from a meta-analysis of 21 RCTs, had an overall number of almost 2,200 patients that compared thyroid replacement with placebo for between 3 and 18 months, and the doses were titrated to a normal TSH, which is what we want to see in an RCT.
00:11:35
Speaker
There was no significant difference in quality of life, thyroid-related symptoms, depressive symptoms, or cognitive function. So that's kind of disappointing when you're really wanting this medication to work, right? There are some limitations here, of course, including a relatively small sample size, and there was no intention to treat analysis.
00:11:57
Speaker
But it certainly seems much more likely that treating these patients is an example of overuse rather than a helpful medical intervention. Yeah, this study formed the basis of a clinical practice guideline that was published in BMJ in 2019. And this guideline was produced by a panel that was made up of patients, endocrinologists, generalists, and methodologists of methodology.
00:12:25
Speaker
How ever you pronounce that word? They're very important people. Yes. So this was a group that was well balanced with a low risk of bias. And because this study included patients with a TSH as high as 19.9,
00:12:41
Speaker
They put out a strong recommendation against treating patients with subclinical hypothyroidism even in the 10 to 20 milliunits per liter range. So strong recommendation even when the TSH is up to 19.9.
00:12:57
Speaker
Exactly. Now they did exclude patients that were younger than age 30 or women who were trying to get pregnant from that recommendation. And we also know that older patients are often underrepresented in trials. So are there any studies looking at older patients as they frequently show symptoms that could be attributed to hypothyroidism? Good question.
00:13:22
Speaker
And yes, I'm happy to say that there are a couple of good RCTs. They're published in 2019 and 2020 that look at the elderly population. One looked at adults 65 and older, and the other looked at adults aged 80 and over. Both studies found no difference between treating with levothyroxine or placebo in reducing thyroid-related symptoms, unfortunately.
00:13:48
Speaker
So when it comes to treating symptoms in patients with subclinical hypothyroidism, levothyroxine just doesn't seem to work and millions of people in the US are taking a medication that they don't need. However, Bobby, I do want to circle back around to cardiovascular risk. So we made that comment earlier. What is the concern with regards to cardiovascular risk in subclinical?
00:14:14
Speaker
Yeah, that concern is understandable based on the results of that cohort study we mentioned earlier in the recording. There was a strong association there, and the AACA guideline, which is a bit old now, recommends treating patients with a TSH over 10, while this new BMJ guideline says don't treat up to 20.
Shared Decision-Making in Subclinical Hypothyroidism
00:14:35
Speaker
So what do you do with that?
00:14:36
Speaker
This is probably a good place for shared decision making, which we seem to talk about every episode. We do. But I like the approach of the BMJ guideline, which suggests monitoring the progression or resolution of thyroid dysfunction instead of just reactively treating. Yes.
00:14:55
Speaker
Okay. So I mentioned earlier that there was a significant flaw in that cohort study and that is that they do not have data on how many patients progressed from subclinical to overt hypothyroidism or how many patients reverted to a youth thyroid state over the course of the study. That seems like something important to know. Yeah. Yeah. So, I mean, we know that patients with higher TSH levels at baseline,
00:15:22
Speaker
are at increased risk for developing overt hypothyroidism. So what if this is a confounding variable where those patients who would progress to overt hypothyroidism are actually the patients who are at increased risk
00:15:38
Speaker
and not all of the patients who are diagnosed with subclinical hypothyroidism. So until we have some RCTs that randomize patients with subclinical hypothyroidism to placebo or treatment,
00:15:53
Speaker
and look specifically at cardiovascular outcomes, we are left with uncertainty. And clinicians and patients will just have to use their judgment. So any researchers out there looking for something to do, here's a good idea. And we'll be happy to report it on our next podcast, right? Yes, as long as it's done well with intention to treat analysis and all the good things that we enjoy. Absolutely.
00:16:20
Speaker
But we also make a point on this podcast to consider potential harms of interventions. And I think most people generally think of levothyroxine as a harmless intervention. But what might be the harms of starting this in a patient with subclinical hypothyroidism?
00:16:39
Speaker
Well, you're right. Levothyroxine is something that I don't cringe when I see on a med list. In fact, I usually find much more harmful medications to focus on when I'm doing my teaching, right? So I do tend to kind of overlook it myself. But let's think about a lifelong medication. No one likes to take a medication every day that they don't need. That seems important to me. We're also committing to monitoring thyroid tests. I would like to think that if you are prescribing this medication, you are.
00:17:10
Speaker
monitoring that, there's a cost that comes with that. And perhaps many of these patients will revert to having a normal TSH level. So as with everything in medicine, nothing is truly benign. There is no, no risk intervention. Yeah, that's true. So what is your take?
00:17:28
Speaker
on the use of levothyroxine in patients with subclinical hypotheters. What are you gonna tell people that are listening to this podcast, is the take home message, what should they do? Right. And again, I hate to just always give both views, but I tend to lean more towards the BMJ guideline. I think a TSH over 20 or 20 or over, we need to treat and treat with medication with levothyroxine.
00:17:56
Speaker
I think if the patient has a TSH between 10 and 20 and they have no symptoms or even just a very mild fatigue, I think that's something that should be monitored. As opposed to if you have a patient who is adamant
00:18:12
Speaker
that their symptoms are not attributed to other comorbidities, their life is going well, their TSH is 15, and they have symptoms, then I'm okay with shared decision-making, monitoring, starting medication, but then objectively trying to follow up with those symptoms. Don't just say, okay, I'm writing this first prescription, I'm giving you 12 refills.
00:18:32
Speaker
you're on this lifelong. I'm always against that. I do think that we need to have an end point and it needs to be more concrete and I think we fall short of that.
00:18:43
Speaker
Yeah, I think that's a reasonable approach. Definitely over 20, we don't have any evidence to suggest not to do it, and so it's probably worth doing it at that point. Between 10 and 20, I understand if somebody's going to start it for the potential of the cardiovascular risk. I get that. I think where I probably would land is a shared decision-making conversation in that scenario.
00:19:07
Speaker
Talking to patients about that and the level of uncertainty there is surrounding that and letting them make a good choice as to what they want. And being really careful not to implicate or over-promise what starting Synthroid or Levothyroxine is going to do for their symptoms.
00:19:28
Speaker
And this, I would probably try to do only after exhaustively thinking through the other possibilities for why they were having those symptoms. I agree. And, you know, I didn't bring this up earlier, but the pharmacist in me kind of goes to the counseling of how to take Levitharoxine.
00:19:46
Speaker
empty stomach, some people stress about that, you Google it, it has drug interactions, whether or not those are clinically significant. There are a lot of patients that, quote, struggle with taking this medication appropriately, and would probably be relieved to know, maybe I don't even need this medicine. I do think that's something that, as clinicians, we kind of forget the day-to-day, how do you take this medicine, but some people really struggle with that, so that's another thing we need to think about.
00:20:13
Speaker
Sure, yeah, that's a great point. Well, thanks, Sandy. You're welcome. Another interesting conversation on something that when we first thought about this topic, I didn't think it was going to be all that interesting. I didn't think we had anything. As I dove into it more, it was going to turn out great. It makes us look kind of sick, doesn't it? It does. We enjoy doing this. I kind of worry about that. Right, I know, I know. Well, this is going to be my commitment, OK, for our residency program.
00:20:42
Speaker
When I see levothyroxine on a med list, I am going to take a moment or two to try to investigate. I'm not going to be ugly about it, but I am going to just pose the question to the resident. Do you really know why this patient is on this medication? Yes or no? And if it's no, then why don't we do some investigation? I think that's fair, right? Yeah, I think so. Okay. For sure. That's my commitment based on this research. Excellent.
00:21:09
Speaker
Thank you, Bobby. Thanks,
Rethinking Bimanual Exams: Necessary or Not?
00:21:11
Speaker
Sandy. All right, so we're going to move to a new segment where we're going to have our first guest on the program. And it is one of our amazing third year residents, Dr. Macy Osborne, as she leads us in the next segment, which we call The Student Has Become the Teacher.
00:21:52
Speaker
So now we'll send it on to Don Kapanis.
00:21:56
Speaker
So Dr. Osborne, thank you for coming on the podcast with us today. You're so welcome. I'm happy to be here. Yeah. You're our very first resident, I believe that is on the podcast. So this is very exciting. Yes. And full disclosure on this topic, you, you gave this lecture a couple of months ago and, um, you, I was post called when you gave the lecture. So I didn't get to hear it, but I did see that you were given this and I, and it was about doing by manual exams on women.
00:22:26
Speaker
and the data and the proof behind it. And I thought to myself, interesting, I do those on women. And it looks as though she's going to go over the data. And I'll look through the PowerPoint slides and thought, hmm, there's new information here that I have not yet incorporated in my practice.
00:22:42
Speaker
So I was very excited to see that you were teaching all this. And also, you know, you're graduating very soon. And this is an example of you're attending not knowing something that you as a resident were teaching. So you will find this very often in your practice going on as an attending. And so this is one of those cases I need the resident to teach me as an attending about the new data. So thank you for coming on to teach me this. You're very welcome. I'm excited about it.
00:23:11
Speaker
So tell me, tell me what did you find? What made you even ask these questions about bimanual exam? Right. So I think that's a good place to start. So the reason I chose kind of this topic to look into is because historically in medical school, you're taught to do a bimanual exam. That's part of a pelvic examination. And that's what I was taught. So I was taught, you know, you examine your external genitalia, examine your internal genitalia, and do your bimanual. You got to palpate those ovaries, palpate the uterus, feel for anything abnormal.
00:23:40
Speaker
And when I got to residency, I was doing those at first. And I had a couple of tendings ask me, well, what did you feel? How did the exam go? And I was like, I don't really know. And then I started kind of looking into things. I was like, maybe I don't need to do these anymore. And so I did. I stopped doing them and didn't know why. So I wanted to look into the evidence and proof of why I stopped doing them and if that was the right thing to do. So that's kind of how I got there. And that's how I delved into it.
00:24:08
Speaker
Interesting. You know, when I was in residency, I had an OBGYN attending tell me if you want to be good at women's health, you need to know how to do a goodbye manual exam. And so I was, I've done them faithfully with every patient literally up till, you know, I have continued to do them. So I'm interested to learn. So tell me when you sort of look into this, what did you find? What, what's the proof?
00:24:29
Speaker
Yeah, so I found that, just like you said, around 2013, ACOG did a study and they asked a bunch of OBGYN physicians, do you do a bimanual exam? And around 90% of those said, absolutely, of course, every single time you need a bimanual examination. And then we start to see this shift in pap smear screening recommendations. So we go from doing yearly pap smears to every three years in their 20s and every five years in their 30s.
00:24:57
Speaker
And this brought up a lot of controversy among OBGYNs because they felt like, are we missing out on those yearly pelvic exams if we're not also doing yearly PAP exams? So I think a lot of this started from that and then sort of branched off.
00:25:12
Speaker
So then ACOG actually looked back at the prostate, lung, colorectal, and ovarian cancer screening trial that was done in 2011. And so this was looking mainly at bimanual examinations and the effectiveness on ovarian cancer screening as well as transvagal ultrasounds and CA125.
00:25:30
Speaker
Because I think when most people are doing a bimanual examination, they are screening for ovarian cancer. You're hoping that you're going to find, well, not hoping that you're going to find, an ovarian mass on that exam. So what they found was bimanual exams weren't very good. So the published study was 79,000 women looking at transaginal ultrasounds and CA125s for screening.
00:25:53
Speaker
And it didn't include bimanual exams there in the published data. But when you look back, they actually did a retrospective analysis on it, looking at the bimanual examination and its sensitivity to detect ovarian masses. And it actually was discontinued after five years, the bimanual exam as part of that study, because there were zero cases of ovarian cancer that were detected by palpation alone. And that's a lot of women.
00:26:18
Speaker
So when you look at the sensitivity of that, it was like 5%. And the positive predictive value was 1%, which are terrible numbers in the world of evidence-based medicine. So then I did a little bit of looking too, like how good are bi-manual exams? Is there any data on that?
00:26:36
Speaker
And I found that they actually did another study looking at the quality of bimanual exams. So in an operating room under a controlled setting, the patients were asleep. So there was, you take out the discomfort of the exam, the examiner is able to do the exam to their comfort level too, and really try to palpate those ovaries. They're not very good. So in a woman who was less than 55 years old, the examiner could only palpate about 55% of those ovaries.
00:27:06
Speaker
which is really low. And so about half the time you're not even feeling a normal ovary. If you were over 55 years old, they were only palpated about 30% of the time. So it's really not a sensitive study or exam at all. And so I didn't feel like I was gaining anything from doing an exam. Wasn't palpating a real ovary anyways, so I stopped doing them. Did you, when you were looking through the data, did you see any benefit in continuing this?
00:27:33
Speaker
So yes, I think it's important to point out that the data that supports continuing a bimanual examination is in the instance where the woman is symptomatic or having bloating symptoms, abdominal pain, things that would lead you to go down maybe an ovarian cancer route, and then you could potentially palpate a mass in there. But as far as catching an ovarian cancer at stage one or two when it's really small, you're probably not going to be able to do that.
00:28:01
Speaker
So certainly, absolutely. Continue for symptomatic women with our complete exam, with a pelvic exam. But for asymptomatic screening, you really have not found any data that shows any benefit. Correct. Tell me about harm. So like, I'm trained to do this. I've been doing it for a long time. What if I just don't want to change? Would I hurt anybody by continuing to do bi-menu exams? So I think that's a great question. So you're not inserting any instruments in the vagina except for your fingers.
00:28:28
Speaker
So you're not going to do any physical harm, but when we think about the psychological effects of getting a bimanual examination as a woman who may already have some insecurities about going into a pelvic exam, it could steer them away from future pelvic exams. It could give them a false sense of security. You say, oh yeah, I didn't palpate anything.
00:28:48
Speaker
When we know that 50% of the time you're not even going to palpate their ovaries, you could give them a false sense of reassurance, which could lead to less exams down the road and that sort of screening mechanisms. But physical harm, probably less.
00:29:06
Speaker
OK, interesting. So tell me, what are you going to do with this information moving forward? Because I'm sitting here thinking, how should this change my practice? Will it change our practice? And I'm still thinking about my response. You tell me what you've come up with.
00:29:22
Speaker
So what I decided based on all the evidence and what I found was that when I'm doing a routine pelvic examination on someone who is asymptomatic, I will not do a bimanual examination regardless of the age of that woman. However, if they are symptomatic,
00:29:38
Speaker
or they are psychologically struggling with the idea that they could have ovarian cancer because their mom or their sister had it, that might change my perspective going forward a little bit. And I would do a bimanual examination in those circumstances, but not on every person for asymptomatic screening.
00:29:57
Speaker
And just thinking, playing a little bit of devil's advocate, you know, so often in family medicine and in medicine in general, we need to know what normal exam is.
Staying Updated with Evolving Medical Guidelines
00:30:08
Speaker
So when we feel something abnormal, we know that it's abnormal, right? So how often do we do an exam and like something's not quite normal here, whether it be a lung exam or in this case, talking about a pelvic exam, a bimanual exam.
00:30:22
Speaker
Um, if we're not doing exams on normal women, will we have the skill set to know what's abnormal in a symptomatic woman? And I don't know the answer. Have you, what are you reading? What are you learning about that? So I think that's a great point. And I didn't find really anything to tell me that, but I know that that's a lot of the OBGYN's concerns as well as if we don't know normal, how do we know abnormal?
00:30:44
Speaker
But I guess my argument would be, do we even really know normal based on the data? And so even if you're in a controlled environment, your patient's asleep, you're relaxed, are you even palpating those ovaries in a normal woman? Yeah.
00:31:00
Speaker
something to think about. I know just from what I'm learning from you right now often in the past I felt like I did not do a complete pelvic exam without that bimanual exam and even if the woman was struggling because of abuse and she was you know just it was in all that she could do to stay on that table I would also do the bimanual and coach her through that.
00:31:25
Speaker
I don't feel guilty not doing that anymore knowing this data and just kind of doing what I have to do, which is that Pap smear. And certainly there have been times that I've done a Pap smear and go take my sample out, take the spectrum out.
00:31:42
Speaker
And the patient starts to sit up and I'm like, no, no, lay down. I need to, I need to finish the exam. You know, if the woman's like done sitting up, I don't know that I'm going to make them lay down. Now, will I bend the practice altogether? Hmm. This makes me question. And I really do appreciate you teaching me this. Absolutely. I think it's what we do in medicine. Things are always changing and we just got to do the best with what we've got and the data that we have. And that's what it's telling us right now. So we'll see what the future holds. Great. Thank you so much for coming on.
00:32:11
Speaker
Thanks for having me.