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Why do so many physicians refuse to prescribe hormonal birth control without a pelvic exam? #943/7

Why do so many physicians still refuse to prescribe hormonal birth control without a pelvic exam and/or pap smear? Pap tests are for cancer screening: the result of the pap test doesn't determine whether the patient can use birth control. Neither the US Food and Drug Administration, the World Health Organization, Planned Parenthood Association, or the American College of Obstetricians and Gynecologists believe that a pelvic exam or Pap smear should be required for hormonal birth control. According to WHO,a pelvic exam for contraceptives (including monthly injectables) is a category C. That is "does not contribute substantially to the safe and effective use of the contraceptive method." So why do doctors still require it? It seems so unethical to me, since consent received under coercion ("you can't have the pill unless you do this") isn't consent at all. It's like requiring men to get prostate exams before prescribing Viagra.

I feel like I could never trust any sort of doctor for ANY health issue because most of them think this sort of coercion is just fine. The fact that many doctors think it's okay to deny child-free or young women sterilization doesn't help either. And it's not even something that affects me personally since I don't have any need for birth control right now. It just seems like something ought to be done to prevent doctors from making decisions that ought to be the patient's. What can be done? (Yes, I'm aware that some studies show a slight increase in cervical cancer after many years of hormonal birth control use. Other studies show no relation. I still think the decision ought to be the patient's.)





Basically, I can find nothing in your comments to disagree with. I certainly concur than a woman should be able to receive oral contraceptives without a pelvic exam.  I think many physicians and many nurse practitioners too are afraid to prescribe pills without that initial exam and Pap test, thinking that otherwise their care is substandard.


I am not sure I would use the term coercion. But I understand where you are coming from.  Recommendations as to when to get the first Pap test have changed lots, and even if a clinician feels that a Pap smear is indicated, it may be wise to delay the pelvic and Pap smear until a subsequent visit in a healthy young woman with no menstrual cycle problems.  As you note, neither the US Food and Drug Administration, the World Health Organization, Planned Parenthood or the American College of Obstetricians and Gynecologists believe that a pelvic exam or Pap smear should be required for hormonal birth control. And according to the World Health Organization (WHO), a pelvic exam for oral contraceptives gets a Category C. That is "does not contribute substantially to the safe and effective use of the contraceptive method."



So, when doctors still require it, is it unethical? Is it coercive?  You suggest that it is like requiring men to get prostate exams before prescribing Viagra. I agree that both a pelvic before pills and prostate exams before Viagra are not necessary. The exams may be beneficial in some instances but are not necessary.

I would tend to say that a pelvic exam is NOT NECESSARY and may be a
DETERRENT to a woman starting pills.

 

I also agree with you that a woman who has not had a child should be able to
have a tubal sterilization procedure performed after all the reasons for later regret have been carefully considered.

 

You can trust many doctors and there are many who will respect a woman's right to choose.

 


What can be done?  Well, for starters, a woman can go to an organization
like Planned Parenthood for birth control services.  Their medical standards
permit providing pills without an initial pelvic exam.  They are willing to perform tubal sterilizations and vasectomies for individuals who do not want to have children.


As you suggest, some studies show a slight increase in cervical cancer after many years of hormonal birth control use.  Other studies show no relationship between pill use and cervical cancer.  You think the decision as to when and how often to have Pap smears don ought to be the patient's. I n most instances, would agree strongly with you.

All I can say to you, once again is that you are right and I agree with you.  I am going to send your initial and follow-up comments and my replies to several people.  I am sure they are going to confirm your criticism.

 

If you would be willing to share it with me, tell me where you are and in what type of medical care setting do you receive services.  Is there an office or a clinic you would like for me to communicate with?

 

            Her reply on 10-3: “Dr. Hatcher, I don’t work in medicine at all.  I’m just a layperson who is interested in this issue and has gotten involved in it.  I am active in a couple of birth control/women’s health internet communications and I see a lot of postings from women who are denied hormonal contraception unless they also get a Pap test and pelvic exam.  I do recommend Planned Parenthood to these people, but Planned Parenthood clinics vary a lot and not all of them offer HOPR, although it seems most do.  I saw a general practitioner last year who refused to treat me for toenail fungus unless I also had a Pap test (no, I am not making this up), so I have no doubt that it happens.  I wasn’t there for any sort of gynecological issue at all.  I was so angry I walked out in the middle of the appointment, but I think a lot of people would have been intimidated enough to just go along with it.  You can post everything except my name.”

 

Dr. Eva Lathrop, how did you handle this in private practice?

 

            Dr. Lathrop’s reply on 10-6: So, this comes up a lot and I think the answer has many parts, depending on the circumstances under which the patient is asking for hormonal contraceptives.  If, for example, she has menorrhagia and wants pills for this, she needs at least a bimanual; however the exam is not to figure out whether or not she can have pills, but to work up her menorrhagia.  If she is an adolescent who wants pills for contraception and has not initiated sexual activity yet and has no active medical problems or past medical history of Gyn significance, then I would not do a pelvic at all.  If she has already become sexually active and did not use safe sex practices, then I would recommend that she have gc/chlamydia testing, but not a Pap per se.  If she refused, I would still give her the pills etc., etc. In the end, it is not a cookbook specialty; these are all sensitive, intimate issues and every woman needs to be addressed in a manner that focuses on her particular needs.  Hope this helps.

 

            Between us, Dr. Eva Lathrop and I gave you a long answer and I hope it helps. We want women to obtain hormonal birth control without a pelvic.  How might you be able to use our response to you to help and how would you suggest that I circulate my response and your question so that it will help other women?

 


Key Words: 
refuse treatment, birth control pills, pelvic examination, Pap smear, cancer screening, effective use, contraception methods, unethical, coercion

Posted 11-8-2007, Updated 11-17-2007, Updated 12-3-2007, Updated 3-25-2008

Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA
---2008-03-25

The directors and owners of this website and any publications and information concerning health matters offered here advise a person with a particular problem to consult a primary-care clinician or a specialist in obstetrics, gynecology, or urology (depending on the problem or the contraceptive) as well as the product package insert and other references before diagnosing, managing, or treating the problem.
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