Pelvic exam necessary for contraception Rx?

Executive Summary

Hormonal oral contraception can safely be prescribed without a pelvic exam, according to guidelines from the World Health Organization and the American College of Obstetricians and Gynecologists.

• In a poll of obstetrician/gynecologists, family medicine physicians, and advanced practice nurses specializing in OB/GYN and women’s health or family medicine, less than one-third of OB/GYNs (29%) and exactly one-third of family medicine physicians (33%) said they always require a pelvic exam when prescribing oral contraception.

• Some advanced practice nurses in primary care (45%) and advanced practice nurses in reproductive health (17%) reported always requiring an exam.

Clinicians at my family planning facility often refuse to give a birth control method if the patient is late for her annual exam,” says a respondent to the 2010 Contraceptive Technology Update Contraception Survey. Is this practice prevalent in the United States?

While some providers might continue to require a pelvic exam prior to providing hormonal contraception, results of a national survey indicate many providers are dropping such restrictions.1 In a poll of obstetrician-gynecologists (OB/GYNs), family medicine physicians, and advanced practice nurses specializing in obstetrics and gynecology and women’s health or family medicine, less than one third of OB/GYNs (29%) and exactly one-third of family medicine physicians (33%) said they always require a pelvic examination when prescribing oral contraception. Almost half of advanced practice nurses in primary care (45%) and some advanced practice nurses in reproductive health (17%) reported always requiring an exam. 

Is a pelvic examination necessary? No, according to national and international guidance. Hormonal oral contraception can be prescribed safely without a pelvic examination, according to guidelines from the World Health Organization and the American College of Obstetricians and Gynecologists.2,3 While weight, blood pressure, and health history are required before prescription of hormonal contraception, screening for sexually transmitted infections and cancer are not necessary to evaluate patients for initiation of oral contraceptive use for birth control, according to authors of the recently published survey results.1 

Requiring a pelvic exam to access birth control is really a “tragic leftover from the past,” says Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles.

“In a beneficent effort to gain more comprehensive care for women, we linked many of the aspects of reproductive health care,” says Nelson. “To motivate women to take their care seriously, doctors did the same.”

Today, clinicians know that requiring an annual pelvic exam prior to continuance of birth control only causes problems, she states. “The truth is that there is nothing in the exam, except the blood pressure, that could keep a woman from being eligible to continue her method, if it contains estrogen,” Nelson observes. “If it is a progestin-only method, even elevated blood pressure would not be a problem.”

 There is generally no need for withholding a method of contraception because someone is late for her exam, advises Susan Wysocki, WHNP-BC, FAANP, president and chief executive officer of the Washington, DC-based National Association of Nurse Practitioners in Women’s Health. It is better to be late for an exam than late for her period, she points out. 

There absolutely is no connection between methods of contraception and getting a Pap test or a pelvic exam, as the most important parts of the yearly exam (as it relates to hormonal methods) are the history and a blood pressure, says Wysocki. The history review can be done quickly over the telephone, which allows the clinician to note changes in medical history and use of new medications, she says. A blood pressure reading can be obtained at any local chain drug store, if the clinician thinks it is necessary. However, the history and the blood pressure can be deferred until the woman can make it into the office for an appointment, states Wysocki.

Knock down barriers

Requiring asymptomatic women to undergo a pelvic examination before dispensing contraception “poses an unnecessary medical hurdle before a critical and time-sensitive medication,” say authors of the current survey analysis.1 In a 2001 study, research shows that hormonal contraception can be provided safely based on careful review of medical history and blood pressure measurement. For most women, no further evaluation is necessary, the 2001 study states.

Refusing to call in a prescription for pills, rings, or patches because a woman is late is “thoughtless,” says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics in the Emory University School of Medicine in Atlanta. In fact, since there is often a delay in scheduling visits, one might even suggest that refusing to call in a prescription for a woman who will be late for her annual exam by the time she needs to obtain a package of pills, patches, or a ring is “perfectly outrageous,” states Hatcher.

“You wonder why 50% of all pregnancies in the United States are unintended?” he observes. “This practice suggests one little part of the answer.” 

References

1. Henderson JT, Sawaya GF, Blum M, et al. Pelvic examinations and access to oral hormonal contraception. Obstet Gynecol 2010;116:1257-1264.

2. World Health Organization. Selected Practice Recommendations for Contraceptive Use. Second ed. Geneva: WHO; 2004. Available at http://whqlibdoc.who.int/publications/2004/9241562846.pdf.

3. American College of Obstetricians and Gynecologists. Guidelines for women’s health care: a resource manual. Third ed. Washington, DC: American College of Obstetricians and Gynecologists; 2007.

4. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs. evidence. JAMA 2001;285:2232-2239. 

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Refusing to call in a prescription for pills, rings or patches because a woman is late returning for her visit is thoughtless.  In fact, since there is often a delay in scheduling a visit for a woman who calls in, one might even suggest that refusing to call in a prescription for a woman who will be late for her annual exam by the time she needs to obtain a package of pills, patches or a ring is perfectly outrageous!

You wonder why 50% of all pregnancies in the United States are unintended.  This query suggests one little part of the answer.

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