It’s a source of worry; a reason why an adolescent female patient might avoid talking about contraceptives; and for some a way to be reassured about overall health. It’s the pelvic exam and the often attendant Papanicolaou (Pap) test. Despite these tests no longer being recommended by organizations such as the American College of Obstetricians and Gynecologists (ACOG), adolescent girls and young women are still undergoing unnecessary pelvic examinations, according to a study recently published in JAMA Internal Medicine.1
Researchers from the Centers for Disease Control and Prevention and the University of California, San Francisco, performed a cross-sectional analysis of data from the National Survey of Family Growth, a nationally representative sample of men and women aged 15 to 44 years.
The sample of adolescent girls and young women aged 15 to 20 years identified in the survey included 3417 participants, with a personal history of gynecologic cancer excluding 7 of the participants for a total of 3410 adolescent girls and young women. Female interviewers conducted interviews with the 3410 young women, and each participant also completed an audio computer-assisted self-interview. The questions asked only about the past 12 months, during which 4.8% of the women had been pregnant; 22.3% had undergone some form of testing for a sexually transmitted infection (STI); and 4.5% had received treatment or medication for an STI. Just 2% of the women reported having an intrauterine device during the previous year, but 33.5% of the participants said that they had used at least 1 form of hormonal contraceptive in the past 12 months.
In the studied period, an estimated 2.6 million individuals had undergone a bimanual pelvic exam (BPE). In addition to the BPE, it was estimated that 2.2 million young women had been given a Pap test over the course of 12 months. The researchers estimated that more than half the BPEs may have been unnecessary and that roughly 75% of the Pap tests performed were not needed.
In 2014, the Medicare payment for a pelvic screening was $37.97 and the payment for a Pap test was $44.78. The potential annual cost of unnecessary BPEs and Pap tests could total more than $123 million, according to the researchers. In addition to the preventable costs for the BPEs, other harms included false-positive findings, overdiagnosis, and the use of unnecessary treatments
Why are these tests still being performed?
A potential reason for the continued use of the BPE in young patients is that it has been a long-standing clinical practice. The researchers cited a 2013 survey of ob-gyns that found an overwhelming majority—87%—would still perform a BPE on an asymptomatic woman who was aged 18 years. Providers may also consider the exam a useful tool to detect gynecologic cancer. However, gynecologic cancers are rare in young women, with a rate of 1.5 cases per 100,000 people, and guidelines do not recommend the exam for the purpose of cancer screening.
The study also pointed to previous inquiries into women’s attitudes and beliefs revolving around BPEs. Many of these inquiries have found that 50% of women aged older than 21 years could not identify a medical reason for undergoing the procedure. However, a number of these same women thought the exam was a routine way to screen for STIs, initiate contraceptive use, detect cancer, and assure the patient’s good health.
Feelings of trepidation about going to exams in which a BPE might be performed can be quite common. This fear can be even more pronounced in adolescents and young women who had a forced first sexual encounter, which is the case for 1 in 16 women of reproductive age. Young women also are seeing stories in the news about doctors who have performed inappropriate gynecologic examinations under the guise of needed medical care; for example, Larry Nassar and the US Gymnastics team scandal.
The current study did have limitations, according to the researchers. One reason was that because it was a survey, there was the possibility that participants were not recalling their experiences accurately, and another possibility that the veracity of the responses was unverifiable. On the other hand, the questions did include a specific description of the BPE as well as the Pap test, and respondents only had to recall information for the previous 12 months. The women weren’t asked specifically about symptoms and were considered symptomatic by the researchers if they stated that the most recent BPE happened due to a medical problem.
Providers can offer education
When asked what health care providers can do to break the cycle of performing pelvic exams that aren’t needed, Paula J. Adams Hillard, MD, director of Gynecology at Lucille Packard Children’s Hospital in Stanford, California, says it is important to inform mothers that Pap tests are no longer recommended for girls aged younger than 21 years. She also recommends being familiar with the ACOG’s Committee Opinion for the first reproductive health visit.
Hillard also has patient resource information to give to adolescent girls informing them of what tests may be required for oral contraceptives. For girls who are wondering or even worrying about what may occur during their first gynecologic visit, she recommends the ACOG’s guide of frequently asked questions.
Finally, to make sure that the patients also know what to expect when they do have to undergo a pelvic exam, Hillard recommends a guide to the first pelvic exam from the Center for Young Women’s Health, which is a part of Boston Children’s Hospital in Massachusetts.
1. Qin J, Saraiya M, Martinez G, Sawaya GF. Prevalence of potentially unnecessary bimanual pelvic examinations and Papanicolaou tests among adolescent girls and young women aged 15-20 years in the United States. JAMA Intern Med. 2020;180(2):274-280.