By Rebecca H. Allen, MD, MPH
Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports she receives grant/research support from Bayer, and is a consultant for Bayer, Mylan, and Merck.
SYNOPSIS: In this cross-sectional national survey, the authors estimated that 23% of women aged 15 to 20 years had received a bimanual pelvic exam, of which half (54%) were deemed potentially unnecessary, and 19% of the population received a Pap test, of which 72% were potentially unnecessary.
SOURCE: 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; Jan. 6. [Online ahead of print].
This is a cross-sectional survey using data from the National Survey of Family Growth, a probability-based sample of U.S. men and women aged 15 to 44 years. For this analysis, the population included 3,410 young women aged 15 to 20 years, combining data from 2011 to 2017. The response rate was 70.4%. The following questions were asked, using trained interviewers: 1) “In the past 12 months, have you received a pelvic examination — where a doctor or nurse puts one hand in the vagina and the other on the abdomen?” and 2) “In the past 12 months, have you received a Pap test — where a doctor or nurse put an instrument in the vagina and took a sample to check for abnormal cells that could turn into cervical cancer?” The participants were asked about main reason for the bimanual exam or Pap test and could choose “part of a routine exam”; “because of a medical problem”; or “other reason.” The authors classified the bimanual exam as medically indicated if it was associated with pregnancy in the past 12 months, intrauterine device (IUD) use in the past 12 months, receipt of an exam because of a medical problem or other reason, and receipt of treatment for sexually transmitted infections (STIs).
The majority of Pap tests were considered unnecessary because cervical cancer screening is not indicated in women younger than 21 years of age, except for young women who are HIV positive and sexually active. Participants in the survey also were asked if they had been tested for STIs or had been treated or received a medication for STIs in the past 12 months, as well as the type of birth control method used in the past 12 months.
Among U.S. women aged 15 to 20 years, 4.8% were pregnant, 22.3% had undergone STI testing, 4.5% received treatment for an STI, and 2% reported using an IUD during the 2011-2017 study period. The prevalence of ever receiving a bimanual exam was 29%, and the prevalence of receiving a bimanual exam in the past 12 months was 23%. The authors estimated that half of these exams (54%) were potentially unnecessary. One-fifth (19%) of respondents reported receiving a Pap test in the past 12 months. The authors estimated that 72% of these Pap tests were potentially unnecessary. In multivariable analysis, females who used hormonal methods of contraception other than an IUD were 31% more likely to receive a bimanual exam and 75% more likely to receive a Pap test than women not using those methods. Receipt of a Pap test was found to be associated with older age (adjusted prevalence ratio [aPR], 1.54; 95% confidence interval [CI], 1.21-1.96), pregnancy (aPR, 2.31; 95% CI, 1.71-3.11), and IUD use (aPR, 3.77; 95% CI, 2.87-4.95).
COMMENTARY
The authors of this study were attempting to estimate how often medical providers were inappropriately performing bimanual exams and Pap tests for women aged 15 to 20 years in the United States. There are some major limitations in the way the study was performed, which are inherent to national cross-sectional surveys. According to the American College of Obstetricians and Gynecologists, a pelvic examination should be performed when indicated by medical history or symptoms.1 Otherwise, among asymptomatic women who are not pregnant, the decision to perform a pelvic exam should be a shared decision-making process with the patient and provider. A pelvic examination for screening purposes — for example, to detect ovarian cancer or STIs and pelvic inflammatory disease — among asymptomatic nonpregnant women is controversial.
We lack data on the effectiveness of the pelvic exam for screening. The U.S. Preventive Services Task Force has stated that current evidence is insufficient to assess the balance of risks and benefits of performing a screening pelvic exam in this population.2 In women younger than 21 years of age, the role of the routine screening pelvic exam is even less relevant. Current recommendations from the Centers for Disease Control and Prevention allow for gonorrhea, chlamydia, and trichomonas screening through self-collected vaginal swabs or urine tests, and a pelvic exam is not required prior to the initiation of contraception other than an IUD.3,4 In addition, cervical cancer screening does not start until age 21 despite sexual activity in the general population.5 The concerns regarding unnecessary pelvic exams are the potential harms, which might include anxiety, discomfort, fear, and embarrassment.1 These harms might be worsened among women with a history of sexual trauma or among adolescents who have never had a pelvic exam before. There is little data on other harms, such as overdiagnosis or overtreatment, due to a bimanual exam, although certainly that can happen with Pap testing.
In terms of the bimanual exam, the authors estimated about half were potentially unnecessary. It is likely that the participants did understand the question regarding the bimanual exam, since it was very clear, so I would judge their answers as accurate. The limitation comes when the subject may not have realized or remembered that there was a medical indication for the exam according to the medical provider. We have no way of knowing the provider’s thought process. In terms of the Pap testing, I see patients all the time who think they have had a Pap test done because a speculum exam was performed. Even though the question is phrased as clearly as possible, many participants may have assumed a Pap test was done when it was not, assuming their doctor should have been checking for cervical cancer. After all, most individuals are not aware that cervical cancer screening does not start until age 21 for the general population.
Furthermore, I do not understand the estimate that only 72% of the Pap tests were potentially unnecessary. That would assume that 28% of the population was HIV positive and sexually active, which is the only indication for Pap testing in women younger than age 21 years. The authors stated that they estimated the prevalence of Pap tests performed as part of a routine examination and considered them potentially unnecessary. I would have assumed the vast majority of the Pap tests would have been unnecessary. Therefore, I think the Pap testing data has some major limitations.
While the numbers in this study may not be entirely accurate, they likely do reflect an overuse of the pelvic exam for adolescents and young women. Adolescents have been shown to avoid STI testing and hormonal contraceptive use for fear of having to undergo a pelvic exam.6 Therefore, the study reminds us to consider when a bimanual exam and speculum exam are absolutely necessary for patient evaluation. I agree that we need to be judicious in pelvic exam use for adolescents, and certainly follow evidence-based guidelines regarding STI and cervical cancer screening, as well as contraceptive provision.
REFERENCES
- [No authors listed]. ACOG Committee Opinion No. 754: The utility of and indications for routine pelvic examination. Obstet Gynecol 2018;132:e174-e180.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. US Preventive Services Task Force. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA 2017;317:947-953.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016;65:1-66.
- Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No 131: Screening for cervical cancer. Obstet Gynecol 2012; 120:1222-1238.
- Westhoff CL, Jones HE, Guiahi M. Do new guidelines and technology make the routine pelvic examination obsolete? J Women’s Health (Larchmt) 2011;20:5-10.
In this cross-sectional national survey, the authors estimated that 23% of women aged 15 to 20 years had received a bimanual pelvic exam, of which half (54%) were deemed potentially unnecessary, and 19% of the population received a Pap test, of which 72% were potentially unnecessary.
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