Unnecessary Pelvic Exams, Pap Tests Common in Young Women

Tara Haelle

January 06, 2020

More than half of bimanual pelvic exams (BPE) given to young women aged 15 to 20 years are likely unnecessary, according to estimates from a study published online today in JAMA Internal Medicine.

Approximately 2.6 million young women — about a quarter of those in this age group — reported receiving a pelvic exam in the previous year even though fewer than 10% were pregnant or receiving treatment for a sexually transmitted infection (STI) at the time.

Similarly, an estimated three in four Pap tests given to women aged 15 to 20 years were likely unnecessary. Based on Medicare payments for screening Pap tests and pelvic exams, the unnecessary procedures represented an estimated $123 million in a year.

"The American College of Obstetricians and Gynecologists recognizes that no evidence supports routine speculum examination or BPE in healthy, asymptomatic women younger than 21 years and recommends that these examinations be performed only when medically indicated," write Jin Qin, ScD, of the Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues.

"Our results showed that, despite the recommendation, many young women without discernable medical indication received potentially unnecessary BPE or Pap tests, which may be a reflection of a long-standing clinical practice in the United States."

These findings "demonstrate what happens to vulnerable populations (in this case, girls and young women) when clinicians do not keep up with or do not adhere to new guidelines," writes Melissa A. Simon, MD, MPH, in an invited commentary. She acknowledges the challenges of keeping up with new guidelines but notes the potential for harm from unnecessary screening. Simon is vice chair for clinical research in the Department of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

The researchers analyzed responses from 3410 young women, aged 15 to 20 years, in the National Survey of Family Growth (NSFG) from 2011 to 2017 and extrapolated the results to estimate nationwide statistics. The researchers found that 22.9% of young women — 2.6 million in the US — had received a bimanual pelvic exam during the previous year.

"This analysis focused on the bimanual component of the pelvic examination because it is the most invasive of the pelvic examination components and less likely to be confused with a speculum examination for cervical cancer or STI screening," the authors note.

More than half of these pelvic exams (54.4%) — an estimated 1.4 million exams — were potentially unnecessary. The authors classified these pelvic exams as potentially unnecessary if it was not indicated for pregnancy, intrauterine device (IUD) use, or STI treatment in the past 12 months or for another medical problem.

Among the respondents, 4.8% were pregnant, 22.3% had been tested for an STI, and 4.5% had been treated for an STI during the previous year. About a third of respondents (33.5%) had used at least one type of hormonal contraception besides an IUD in the past year, but only 2% had used an IUD.

Simon writes that some have advocated for routine bimanual pelvic exams to prompt women to see their provider every year, but without evidence to support the practice.

"In fact, many women (younger and older) associate the bimanual pelvic and speculum examinations with fear, anxiety, embarrassment, discomfort, and pain," Simon writes. "Girls and women with a history of sexual violence may be more vulnerable to these harms. In addition, adolescent girls may delay starting contraception use or obtaining screening for sexually transmitted infections because of fear of pelvic examination, which thus creates unnecessary barriers to obtaining important screening and family-planning methods."

The researchers also found that 19.2% of young women, about 2.2 million, had received a Pap test in the previous year. The majority of these (71.9%) were likely unnecessary, they write, explaining that cervical cancer screening is not recommended for those under 21 years unless they are HIV-positive and sexually active.

"Because HIV infection status is not available in the NSFG, we estimated prevalence of Pap tests performed as part of a routine examination and considered them potentially unnecessary," the authors explain.

Young women were seven times more likely to have undergone a bimanual pelvic exam if they received a Pap test (adjusted prevalence ratio [aPR], 7.12). In fact, the authors report that nearly all potentially unnecessary bimanual pelvic exams (97.7%) occurred during the same visit as a Pap test that was potentially unnecessary as well.

Young women were also more likely to receive a bimanual pelvic exam if they underwent STI testing or used any hormonal contraception besides an IUD (aPR, 1.6 and 1.31, respectively). Those with public insurance or no insurance were less likely to receive a pelvic exam compared with those who had private insurance, though no associations were found with race/ethnicity.

Young women were about four times more likely to have a Pap test if they had STI testing (aPR, 3.77). Odds of a Pap test were also greater among those age 18-20 (aPR, 1.54), those with a pregnancy (aPR, 2.31), those with an IUD (aPR, 1.54), and those using any non-IUD hormonal contraception (aPR, 1.75).

Staying up to date on current guidelines and consistently delivering evidence-based care according to those guidelines "is not easy," Simon writes. It involves building and maintaining a trusting clinician-patient relationship that centers on shared decision-making, keeping up with research, and "unlearn[ing] deeply ingrained practices," which is difficult.

"Clinicians are not well instructed on how to pivot or unlearn a practice," Simon continues. "The science of deimplementation, especially with respect to guideline-concordant care, is in its infancy." She also notes the value of annual visits, even without routine pelvic exams.

"Rethinking the goals of the annual health examination for young women and learning to unlearn will not put anyone out of business," Simon concludes. "Rather, change can increase patients' connectivity, trust, and engagement with primary care clinicians and, most importantly, avoid harms, especially to those who are most vulnerable."

No external funding was used. The study authors and Simon have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 6, 2020. Abstract, Editorial

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