Results of a nationally representative study indicate that many young women receive gynecologic exams that may be unnecessary, and not in compliance with the latest ACOG guidance.
"This article has been edited to clarify ACOG's position on bimanual exams and Pap tests in adolescents."
Results of a nationally representative study indicate that many young women receive bimanual pelvic exams (BPEs) and Pap tests that may be unnecessary, and not in compliance with the latest guidance from the American College of Obstetricians and Gynecologists (ACOG).
ACOG notes that for an adolescent reproductive health visit, an internal pelvic exam may be appropriate if issues such as abnormal bleeding or discharge, or abdominal or pelvic pain is a concern, but that an adolescent may visit a gynecologist several times before a biannual exam is needed. If a speculum or bimanual exam is indicated, a thorough explanation should always precede the procedure. Patients can find information about a gynecologic visit in the ACOG FAQ document, "Your First Gynecological Visit (Especially for Teens)". Pap tests are not recommended until age 21.
Published in JAMA Internal Medicine, the new findings are from a cross-sectional analysis of the National Survey of Family Growth (NSFG) from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years. The main outcomes were receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests.
Conducted by the National Center for Health Statistics, NSFG is performed by trained personal interviewers and some respondents answer the questions using a computer-assisted self-interview. Of the young women surveyed, 4.8% were pregnant, 22.3% had undergone testing for a sexually transmitted infection (STI) and 4.5% received treatment or medication for an STI in the past 12 months. Only 2.0% reported using an intrauterine device (IUD) and 33.5% used at least one other type of contraception in the past 12 months.
Having a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR] 7.12; 95% CI, 5.56 to 9.12), testing for STIs (aPR 1.60; 95% CI, 1.34 to 1.90) and using hormonal contraception other than an IUD (aPR 1.31; 95% CI, 1.11 to 1.54). It was also associated with being older (aPR 1.25; 95% CI, 1.08 to 1.45). Young women who had a Pap test were seven times more likely to also report receiving a BPE (aPR 7.12; 95% CI, 5.56 to 9.12). Using hormonal contraception other than an IUD was associated with a 31% higher risk of receiving a BPE than in women who did not use those forms of contraception. This is in spite of ACOG’s clear statement that “A pelvic examination is not necessary before initiating or prescribing contraception, other than an intrauterine device, or to screen for STIs.”
Looking at the impact of insurance, the authors found that young women with public or no insurance were less likely to receive a BPE than those with private insurance. Race/ethnicity and STI treatment were not found to be associated with having a BPE when adjusting for other covariates.
Among US young women aged 15 to 20 years surveyed in the years 2011 to 2017, approximately 2.6 million reported having received a BPE in the last 12 months. The authors estimated that more than half (54.5%) or 1.4 million of those exams may have been unnecessary. An estimated 1.6 million of the women, the researchers say, may have had an unnecessary Pap test during the same period.
Based on the results of their analysis and assuming that a Medicare payment for a screening BPE of $37.97 and for a screening Pap test of is $44.78, as was the case in 2014, the authors estimate that the potentially unnecessary BPEs and Pap tests would have cost more than $123 million in 1 year.
Commenting on the findings, the researchers concluded that they “suggest the need for education for health care professionals, parents, and young women themselves to improve awareness of professional guidelines and the limitations and harms of routine pelvic examination and Pap test and to ensure that these tests and examinations are performed only when medically necessary among young women.”