Should a Woman Who Has Never Been Sexually Active Receive a Pap Smear Before Starting Birth Control?

Patricia (Pat) A. Camillo, PhD, RN, APRN-BC

Disclosures

October 07, 2004

Question

When starting a young woman on birth control, even when she is not sexually active, how important is it to obtain a yearly Pap smear? I was always taught that it was mandatory but am finding that many providers refuse to do Pap smears on self-proclaimed virgins but will start them on birth control without one. What is the best approach?

Jeanne Rodman, FNP

Response From Expert

 

Pat Camillo, PhD, RNC, WHNP, GNP 
Associate Professor and Director, The Women's Health Program, Seton Hall University, College of Nursing, South Orange, New Jersey.

 

Over the past decade, questions have been raised regarding the evidence-based need for pelvic exams and Pap smears, especially in regard to the initiation of oral contraceptives. There is consensus among several prominent healthcare organizations that the pelvic exam and Pap smear are not required, at least during the initial visit. These organizations include the US Food and Drug Administration,[1] the World Health Organization,[2] Planned Parenthood Association,[3] and the American College of Obstetricians and Gynecologists.[4]

There are certainly many good reasons to do a pelvic exam and Pap smear, but initiation of birth control, specifically oral contraceptives, is not one of them. There is nothing that will be discovered in this exam, especially in a young woman who has never had intercourse, to significantly affect the practitioner's decision making. The epidemiology of cervical cancer assumes sexual activity. Furthermore, it is highly unlikely that this young woman will have a uterine fibroid or malignant ovarian tumor. Bimanual exams are not recommended for screening ovarian cancer because there is no evidence to suggest that it affects the mortality rate. In addition, false positives often lead to unnecessary interventions. When weighting the benefits vs the risks, it is far more likely that a young woman will get pregnant or experience a sexually transmitted infection, especially if she delays seeking healthcare because she is fearful of the exam.[5]

Regardless of whether a woman is a virgin or plans to be sexually active, the need for an extensive medical history and blood pressure screen is critically important in order to uncover contraindications related to contraceptive use. Those women who have absolute contraindications to oral contraceptive use include smokers over the age of 35 years, women suspected of having breast cancer, or those who have undiagnosed abnormal vaginal bleeding, impaired liver function, known or suspected pregnancy, and elevated blood pressure and/or thromboembolic disorders, past and present, including any condition that predisposes a woman to this condition.[6] These conditions would not be found during a routine pelvic exam, nor would evidence of a very early pregnancy.

In terms of follow-up visits, there is no direct evidence to determine the optimal starting point or interval for pelvic exam and Pap smear screening. The American College of Obstetricians and Gynecologists,[7] the US Preventive Health Services Task Force,[8] and the American Cancer Society[9] recommend that all women, including virgins, have a pelvic exam and Pap smear by age 21, even if they are not sexually active, or within 3 years of sexual activity (if they are under age 21). If a young woman has not had intercourse, there are very small speculums, including nasal speculums, that can be used to make this exam as comfortable as possible.

Women have been taught that they need a pelvic exam and Pap smear every year but we now have evidence that this practice is not necessary and may actually increase the risk for unnecessary interventions. Each woman's situation is unique, and before any examination or procedure is done, the practitioner should always ask, "Why am I doing this?" The answer to this question will help guide clinical practice and provide the best care for that particular woman.

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