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Women seeking birth control get unneeded pelvic exams

Many doctors require that women have pelvic exams before they can get prescriptions for birth control pills, despite guidelines saying that the step is unnecessary, a new study finds.
/ Source: Reuters

Many doctors and other health care workers require that women have pelvic exams before they can get prescriptions for birth control pills, despite guidelines saying that the step is unnecessary, a new study finds.

In a survey of 1,200 U.S. doctors and advanced practice nurses, researchers found that one-third said they always required women to have a pelvic exam before they would write a prescription for birth control pills.

An even higher percentage — 44 percent — said they "usually" required one, according to findings published in the journal Obstetrics & Gynecology.

The number of practitioners requiring a pelvic exam is disappointingly high, researchers say, considering the fact that the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG) advise that birth control pills can safely be prescribed without the exam.

"We were surprised, and we were certainly hoping that the numbers would be lower," Dr. George F. Sawaya, one of the researchers on the study, told Reuters Health.

Unnecessary hurdle
The key problem with mandatory pelvic exams is that it puts up an unnecessary hurdle to women seeking effective birth control, according to Sawaya and his colleagues at the University of California, San Francisco.

Women have to wait until their provider can fit the exam into his or her schedule; some may be turned off by the requirement altogether and opt for less-reliable forms of contraception, like condoms.

Birth control pills are the most popular form of reversible contraception in the U.S., used by 28 percent of women using contraceptives, the authors note.

"In my view, we should have as few barriers as possible to women trying to get effective birth control," Sawaya said.

Dr. Andrew M. Kaunitz, an ob-gyn not involved in the study, agreed.

Pelvic exams, which can find potential signs of sexually transmitted infections, ovarian cysts, cancer or other disorders, are an important part of women's routine healthcare, said Kaunitz, a professor and associate chairman of obstetrics and gynecology at the University of Florida College of Medicine-Jacksonville.

"But pelvic exams should not be linked to oral contraception in a mandated fashion," he told Reuters Health.

There is no established medical need for women to have the exam before receiving a prescription for birth control pills, Sawaya said. It's just that, traditionally, pelvic exams have been coupled with contraceptive prescriptions; in many cases, it may have simply been convenient for women to have a pelvic exam as part of their routine healthcare at the same time they were seeking a birth-control prescription.

"The two just became linked," Kaunitz agreed. But while there is nothing wrong with that, he said, "women also deserve the option of un-linking those two services."

The current findings are based on a survey sent to a national sample of 1,196 ob-gyns, family doctors and advanced-practice nurses specializing in either women's health or family medicine.

Overall, 29 percent of ob-gyns and 33 percent of family doctors said they always required a pelvic exam for women seeking birth control pills. In addition, half of ob-gyns and about 45 percent of family doctors said they usually required the exam.

Nurses least likely to require exams
Advanced-practice nurses specializing in women's health were the least likely to require a pelvic exam, with 16 percent saying they always did so. In contrast, nurses specializing in family medicine were more likely than all other providers to always require a pelvic exam; 45 percent said they did.

The reasons for the high rates are not clear from the study. But simple tradition could be at work, according to both Sawaya and Kaunitz. "I think old habits die hard," Kaunitz said.

He also pointed out that among all providers in the study, those working in private practice were twice as likely as those in community and family-planning clinics to require a pelvic exam — suggesting that the clinic providers are more aware of current guidelines.

It's also possible that some doctors require a pelvic exam in order to get the insurance reimbursement, Sawaya and his colleagues note in their report.

Medicare pays doctors about $75 for a screening pelvic exam and, depending on geography, private insurers may pay more. Contraceptive counseling, on the other hand, may not always fall into a clearly defined reimbursement category, the authors note.

"In the absence of adequate financial incentives for contraceptive counseling as an important clinical activity in its own right," the researchers write, "providers are incentivized to conduct a physical exam with a well-reimbursed billing code.

Exams raise risks of more unnecessary tests
Along with added costs, unneeded pelvic exams also open women up to the possibility of having an abnormal finding that, upon further testing, turns out to be nothing. "Any (test) we do with an asymptomatic person has a chance of resulting in a false-positive," Sawaya pointed out.

As for how often women should have a routine pelvic exam in the absence of any problems, there is no specific guideline. There are guidelines, however, for how often women should get a Pap test to screen for cervical cancer, which is often done in conjunction with a pelvic exam.

According to ACOG, women should begin having Pap tests at age 21, with screening repeated every two years until age 30. Women age 30 and older who have had three consecutive negative Pap tests can be screened every three years.

For women who are only seeking a birth control prescription and are told they need to schedule a pelvic exam, Sawaya suggested they ask their provider why the exam is necessary.

But he said the real message of the survey results is for practitioners, who, based on these findings, need better awareness of current guidelines on birth control prescription.