More articles Questioning the Practice of Pelvic Exams

[marionravenwood.livejournal.com]

Questioning the Need for Routine Pelvic Exam
Commentary Argues It Deters Regular Gynecological Care




Of all the indignities that women endure in their lives, one of the most dreaded is the routine pelvic exam.

Many women find it embarrassing, invasive and even painful. And being instructed to "relax" frequently has the opposite effect.

Now, a commentary in the January Journal of Women's Health has raised a provocative argument: For healthy women with no symptoms of disease, a routine pelvic exam serves little purpose—and may be so disliked that it dissuades some women from getting regular gynecological care.

"If a woman is asymptomatic and feeling fine, getting naked on a table with stirrups and a speculum is not adding extra value," says lead author Carolyn Westhoff, a professor of Obstetrics and Gynecology at Columbia University Medical Center and of epidemiology at the Mailman School of Public Health. "We should be talking about diet and exercise and immunizations—and having time to listen to what she's worried about. We can let go of something that is uncomfortable and embarrassing and not that useful."

In fact, the American College of Obstetricians and Gynecologists (ACOG) is re-evaluating its recommendations on the subject. "We are looking at this very closely," says Cheryl Iglesia, chair of ACOG's Committee on Gynecologic Practice.

Traditionally, a key reason for doing a pelvic exam has been to take a Pap smear—a sample of cells on the cervix to check for signs of cervical cancer—long recommended annually. But in late 2009, ACOG revised its recommendations for Pap smears to every two years for women ages 21 and 30 with no symptoms or other risk factors, and every three years from 30 and older.

Given that change, ACOG is rethinking other elements of the annual exam as well, says Dr. Iglesia. "There may be times when [a pelvic exam] is not necessary and your 15 minutes of managed-care time may be better spent talking."
What's in a Pelvic Exam?

Some of the checks done in routine visits may be done by other means.

Cervical cancer. Annual pap smears that sample cervix for abnormal cells have helped reduce cervical cancer significantly; ACOG now recommends them every two years from ages 21 to 30; every three years after that for women with no health issues.

Ovarian cancer. Odds of survival are much greater when diagnosed early, but studies show that the bimanual check is not effective in finding Stage 1 cancers.

Fibroids, cysts, endometriosis. Many of these can be felt with a bimanual exam before they cause symptoms, and early intervention can stave off fertility problems and pain. But sonograms provide more detailed information and many such abnormalities resolve on their own.

Sexually transmitted diseases. Can be detected via urine or blood tests or self-administered swabs, but some are asymptomatic so women may not know to be tested outside of a routine pelvic exam.

Contraception. Pelvic exam is needed to insert an IUD or fit a diaphragm but isn't necessary for prescribing pills or patches.

Visual exam of vagina, uterus, external organs. Can provide information on injuries, hormone levels, cancers and other issues not available otherwise.

Source: Journal of Women's Health, January 2011; WSJ reporting

In addition to the Pap smear, an ob-gyn also traditionally uses a pelvic exam to check the ovaries and uterus for signs of cancer. The ob-gyn uses two fingers to palpitate the organs inside while pressing on the patient's abdomen from the outside, the so-called bimanual exam.

But Dr. Westhoff and her co-authors point out that bimanual exams don't lead to earlier diagnoses of ovarian cancer and aren't recommended for that purpose by ACOG, the American Cancer Society or the U.S. Preventative Service Task Force. They are seldom performed in the United Kingdom, where the proportion of women diagnosed with Stage 1 ovarian cancers is the same as in the U.S.

Bimanual exams do sometimes lead to additional tests and procedures, such as having ovarian cysts or fibroids removed that may have resolved on their own, says Dr. Westhoff, who notes that one reason ACOG moved away from annual Pap smears was that abnormalities seen there sometimes led to laser excisions or biopsies that could harm a patient's fertility unnecessarily. When women do have symptoms, such as abdominal pain, backache or irregular bleeding, ultrasounds can reveal more information than palpitation can, she adds.

Pelvic exams are also commonly used to screen for sexually transmitted diseases and before prescribing contraceptives. But the authors note that chlamydia and gonorrhea can be detected just as well via blood or urine tests or with swabs that women can administer themselves. And while a pelvic exam is needed to fit a diaphragm or insert an intrauterine device for birth control, there's no need for one before prescribing the pill or a patch.

"I don't want a young woman to be afraid to come in for contraception because she's afraid she'll get a pelvic exam," says Dr. Westhoff. "The pelvic exam is irrelevant to starting the pill. But a substantial portion of doctors still require one. I think a lot of them have just been taught that that's the thorough way to take care of patients, and nobody has stopped to ask, 'What are you looking for?' "

Some other ob/gyns say a pelvic exam can provide numerous clues to a patient's condition. "There's a treasure trove of information you can glean from a pelvic exam," says Laurie Green, a San Francisco ob/gyn.

For one thing, Dr. Green says she can gauge roughly how close a woman is to menopause from the color of her vaginal walls, and says she has occasionally spotted malignant melanomas. She has also spotted cancers during the rectal portion of the exam, and cervical polyps that can make intercourse painful.

Bimanual exams can sometimes detect early stages of endometriosis, an overgrowth of uterine lining outside the uterus, and fibroids that may be asymptomatic now but can pose problems later. "I've had patients who get pregnant and they come in with massive fibroids, and if the fibroids had been removed earlier, they would have a much lower risk for preterm labor," says Dr. Green. "You would lose all of that if you didn't do a pelvic exam."

And while many women detest the pelvic exam, some consider it a crucial part of the visit. Mary Jane Minkin, a professor of ob/gyn at Yale University School of Medicine, says that with the older women she sees in her private practice, "I'm discussing their general health, health habits, weight, exercise regimens, smoking, sexual issues—all of it important—but what sanctifies the visit is the pelvic exam."

Without it, she wonders, "Would they really come in regularly for the health counseling and would insurance reimburse for it?"

Another issue is litigation, Dr. Minkin says. "If something could have been picked up on a pelvic exam and a pelvic wasn't done, do we get sued?"

Dr. Minkin also cautions that while women in monogamous relationships aren't at high risk for cervical cancer, some women only think their relationship is monogamous, so an annual check provides additional protection.

Whether it's done every year or less frequently, a pelvic exam is still necessary periodically, and some doctors, at least, are focusing on ways to make it less uncomfortable for patients.

Robert Reid, a professor of ob/gyn at Queens University in Kingston, Ontario, has developed a video giving medical students more guidance on how to give a "compassionate" pelvic exam. The tips include warming the speculum and testing it on a patient's skin first as well as explaining every step so there are no surprises.

"This is from over 30 years of watching novices make mistakes," he says. The video has been adopted by Canada's Association of Professors of Obstetrics and Gynecology, which distributes it to all Canadian medical schools, and it will be demonstrated at a conference of U.S. ob/gyn professors in San Antonio next month.

Write to Melinda Beck at HealthJournal@wsj.com

I am, of course, offended and enraged that the justifications for exams are money, fear of litigation, and that it "sanctifies" the visit. What the hell? I would also argue against the idea of a pelvic exam being "necessary periodically," unless it is to evauate symptoms. If it's not necessary, it's not necessary, period.

See also:

http://www.managingcontraception.com/newsevents/dr-bob/pelvic-exam-necessary-for-contraception-rx/

http://www.racgp.org.au/afp/200806/200806stewart.pdf

http://www.nlm.nih.gov/medlineplus/news/fullstory_105865.html :
"Many doctors require that women have a pelvic exam before they can get a prescription for birth control pills, despite guidelines saying that the step is unnecessary, a new study finds[....]Overall, 29 percent of ob-gyns and 33 percent of family doctors said they always required a pelvic exam for women seeking birth control pills. In addition, half of ob-gyns and about 45 percent of family doctors said they usually required the exam. Advanced-practice nurses specializing in women's health were the least likely to require a pelvic exam, with 16 percent saying they always did so. In contrast, nurses specializing in family medicine were more likely than all other providers to always require a pelvic exam; 45 percent said they did."

I would have guessed, from people reporting here at VP and elsewhere, that the actual percent of doctors requring (or at least, appearing to require) pelvic exams before precribing HBC is actually much higher than above. What I don't understand is, where's the outrage? Why do I feel like I'm the only one furious about the unnessary hurdles placed on people seeking birth control? It has eroded what little trust I ever had for the medical profession (since more health care providers really ought to be speaking out against it) and made me feel as if I have to be adversarial and hyper-viligant any time I need any sort of health care.

Comments

[lenny-maybe.livejournal.com]

reading stuff like this really scares me. i would hate to have a full pelvic exam just to go on birth control. i just had to go and see my gp for my birth control prescription, and we simply had a short conversation about my medical history to determine if i was suitable. she advised me to have a pap done while we were talking about it, but it wasn't a requirement.

it amazes me that women in some countries have to see an gyno for such routine things. i've never seen one. i've only had to deal with a gp, and will only ever have to deal with a gp unless i need specialist care.

[kr3851.livejournal.com]

i was lucky also, that I didn't need a full pelvic exam for my birth control. I only had one when I became sexually active, and it turned out that I had some abnormal cells and needed a gyno's valued opinion. I can only imagine the terror I would have felt if that all happened when I was 18 (and nowhere near ready to be having sex, let alone a complete stranger poking around my bits - I only went on it to control my periods) instead of at 26 when it did happen. It would have put me off completely, and I wouldn't have ever started the Pill. I'd hate to think how many teen pregnancies occur because girls are too scared to have a full pelvic exam.

[atalanta0jess.livejournal.com]

FWIW, women in the US don't HAVE to see a gyno for routine care. It seems pretty standard to do so, but most GPs can do paps and such, if you request them. It seems to be more just convention that leads many of us to seek our reproductive care from a gyno.

[neko-loliighoul.livejournal.com]

Idont even know how to respond to this, other than to say I have had 2 bimanual exams and the first led to ultrasound because I have a strangely shaped uterus and she was worried about fibroids. however I have also had an ultrasound years later to check again for fibroids due to extremely heavy periods.... hmm. the bimanual exams didnt bother me in any way, and I went to a family planning clinic so didnt have to pay for them.
I suppose those that may have a problem with having a bimanual exam ( vaginismus for example) should be able to easily request to have an ultrasound instead.
pap smears however are important and honestly if you are ok with having them every 2 or 3 years, how is yearly different?
I guess it just doesnt bother me...but maybe that is coming from a place of privilege.

[neko-loliighoul.livejournal.com]

oh and I didnt have to have a pelvic exam either time I went on hbc, just a pregnancy test on a blood test I was already having, for the doctor's "peace of mind" haha

[marionravenwood.livejournal.com]

pap smears however are important and honestly if you are ok with having them every 2 or 3 years, how is yearly different?

I see you are in Australia, so consider yourself lucky you've never had to deal with the system in the US.

I'm opposed to annual pap tests because there's no evidence they decrease mortality from cervical cancer any more than testing every three years, and people tested annually are more likely to have excessive followup testing. Not to mention the huge cost and anxiety involved with testing such a huge number of people annually.

But the real issue is that most doctors in the US won't prescribe birth control without an annual pelvic exam and pap test, even though both have been proven to have no relationship with using birth control safely. That's sick and unethical--it's using birth control as a reward for "compliance," in cancer screening and for (in the case of pelvic exams) something that has no proven benefit, period. It's messed up. It's like they're saying "Be a good girl and get this invasive test, and then we'll let you have sex!" Moving to pap testing every two or three years would do a lot to change this, I hope, since it would force doctors to break the habit of pairing pap tests with birth control prescriptions. That said, it is wrong to require a pap test EVER for birth control, even if the patient chooses to NEVER have one.

I went to a family planning clinic so didnt have to pay for them.

Not everyone has that option, though, and even if you directly don't have to pay for them, someone somewhere does. I am not saying you shouldn't have had that exam, since it sounds like you were evaluating symptoms, but for asymptomatic people who are just getting exams because they're a requirement for birth control? In the US that's a huge expense, and someone pays for it: if it's not the individual, it's the insurance company (which goes back to the individual, since everyone pays for higher premiums) or the government (which goes back to everyone again since it comes out of taxes). If it's a donation funded family planning clinic like Planned Parenthood, then that means all the money and time that goes on unneeded exams could actually be going to something useful like more birth control.

[atalanta0jess.livejournal.com]

"how is yearly different?"

As others have said, yearly is different because of finances. Yearly is different because for some women it is traumatic or painful to get a pap smear. Yearly is different because not everyone has childcare, or the ability to take a day off of work.

I, like you, am not really bothered by getting a pap smear. I have insurance, my work/school schedule is extremely flexible, and it's not a terribly unpleasant process for me. What I DO have a problem with, though, is the offensively high level of paternalism that is present in the practice of medicine, at least in the US. We should be able to trust that our doctors recommendations are based on actual medical reasoning and evidence, rather than tradition, reimbursement, or so that they can keep a closer eye on us. Conversations about medical screening should be honest, and should include both the risks and benefits of doing said screening on the recommended schedule. I want my doctors to allow me to make informed decisions about my OWN health care, based on TRUE, evidence based, straightforward information. Not based on THEIR decisions about what is right for ME. And honestly, THAT is a big difference between once a year, and every couple of years.

I also want to know that my money is being well spent, whether it's my pocket money or my tax money. Part of that means providing health care in a sensible way, rather than providing the vast over-screening that takes place as a part of our litigious society.

[indis-earfalas.livejournal.com]

There is no reason at all that a pelvic exam should be required for HBC. The idea is ridiculous.

BUT!!!!

What I would really like to be examined is why the hell a pelvic exam is considered so embarrassing. They're hardly fun - and for some people they can be downright painful for various reasons - but I really do wonder if *part* of what makes the exam such a shitty thing to go through is all of societies moralistic bullshit that seems to go hand in hand with having a vagina.

[marionravenwood.livejournal.com]

but I really do wonder if *part* of what makes the exam such a shitty thing to go through is all of societies moralistic bullshit that seems to go hand in hand with having a vagina.

Probably, but I would also suggest that the reason pelvic exams are so pervasive is the same moralistic bullshit. Women are evil and dirty and will fall apart without constant monitoring, therefore we need to check them out to make sure they're ok to have sex.

[paraxeni.livejournal.com]

It's not necessarily about 'embarrassment'. Rape and abuse survivors are being forced into having themselves penetrated by someone they're supposed to be able to trust, who is using misinformation and scare tactics to accomplish this. There are people with pain problems that can make such an examination agonising and have effects that last for days. There are people with vaginas who do not identify as female, and who find being reminded of their organs triggers self harm or suicidal ideation. But none of this explanation to you is even necessary, because the point is that the exams are not needed. Bimanuals can detect very little beyond the fact that someone has a vagina. Paps carried out before sexual contact are virtually pointless, and paps done before cervical maturation cause false positives and lead to unnecessary procedures that can damage fertility and cause psychological mayhem.

[chasing-breezes.livejournal.com]

I've never, ever heard of anyone where I live having to have a pap to access birth control of any form. I went to the GP, had a chat about what my needs were and my medical history relevant to what I wanted, and walked out with a prescription. Here the suggestion is a pap smear every two years from the time you become sexually active or age 21. That's it.

Maybe because it's so different to the way things are done here, but to me it just smacks so much of that 'abstinence only, sex is shameful and dirty' mindset... I can't even articulate why, but having to go though such an invasive procedure to be granted access to what equates to reproductive/sexual autonomy rubs me the wrong way. Badly.

[kindragon.livejournal.com]

i had to. i was given 1 month supply, and had to make another appointment for the exam before the doc would give me a year prescription. i had been having sex, but using condoms, as i wasn't on bc, so i still don't think the exam was all that necessary. the usa, and being here in arizona is getting to be a joke in regards to getting proper health care.

[helenkacan.livejournal.com]

What I don't understand is, where's the outrage? Why do I feel like I'm the only one furious about the unnessary hurdles placed on people seeking birth control?

Precisely because the hook that's used is NO hbc unless you comply, probably with a side of arrogant because I'm the doctor and you're not. If you add to that the shame women are made to feel for being sexual creatures (how can this still be so in this century???), then few will dare to come out because of the stigma still associated with unmarried sex for women.

Because most doctors can't make as much money (in a fee for service system) treating men on a routine basis (at least that's how it was historically with men far more reluctant to visit a doctor), they have a special incentive to maintain a stranglehold over this particular medical field, especially as the opportunity for it is - in a way - gift wrapped and delivered right into their hands.

It may come as a surprise to younger readers of VagPag of the 1960s experience that Gloria Steinem had as an undercover Playboy bunny (though, TBH, she wasn't famous yet, so it was just a job in order to write an article). She exposed the fact that the bunnies were forced to have (IIRC) monthly gynecological exams!!!!! Note that I'm not talking about centrefolds with their revealing closeups of female genitals that might have something to do with aesthetics. But just on the tightly-trussed bunnies with their uplifted boobs. Obviously, the totally unnecessary and intrusive examinations were a part of not only keeping women down, but seen as a perk of being on medical retainer to Playboy. Can you say "sexist jerks"???

Anyway, that's just my wee bit of historical perspective. And, in a moment of nostalgic weakness, do I ever miss the 1970s.

Oh, wait. "Sanctified"??????? Obviously the God-complex is alive and well. Arrgghh.

[helenkacan.livejournal.com]

Robert Reid, a professor of ob/gyn at Queens University in Kingston, Ontario, has developed a video giving medical students more guidance on how to give a "compassionate" pelvic exam. The tips include warming the speculum and testing it on a patient's skin first as well as explaining every step so there are no surprises.

"This is from over 30 years of watching novices make mistakes," he says.

I had to come back, to highlight this. WTF??? It took 30 years to come to the conclusion of "Ur doing it all rong"!?!?!

Okay, I can feel my b.p. rising, so I'll just go back to my jasmine tea.

[paraxeni.livejournal.com]

Oh I'm properly outraged about it, but sadly I live across the pond, so it's only on behalf of my American sisters (and brothers) who are treated like they are diseases waiting to happen because OMG!VAGINA. Every time I see someone berating someone else for not getting their 'annual' I honestly want to cry, because doctors have enlisted people with vaginas to pressure other people into complying. When I step in and tell someone that they're not going to die without a yearly bimanual and a breast exam they just don't believe me. When I say that those things just don't happen at all over here, and that paps are only done at 25+ I'm met with disbelief. They ask "Well why are they done, must be for a reason?" the answer "Power and control" gets one of two reactions - either shock, or the "USA #1" type of response that insists it's for the best, that Europe is a collection of backward little villages.

The most upsetting thing of all is when poor people unable to access care, or the dysphoric, or VIRGINS (for crying out loud) are patronised and pressured into something that's at best unnecessary, and at worst detrimental to them.

I try my best to blow the lid off the thing on my internet travels, but I'm only one person. It's very frustrating.

[orangecrush1189.livejournal.com]

Oh wow. I assumed all the outrage was going to be about people saying the exams were unnecessary. Am I the only one who thought my (free, based on my income level at my health department) exams have always been easy, educational (they even held up a mirror so I could see what my cervix looked like!) and beneficial? I am in the bible belt of the US, and am well acquainted with the awful abstinence only sex ed and the way women are taught to be afraid of their vaginas and all that. I just never got that from an exam, and I've been getting them since I became sexually active at 17, which was almost 8 years ago.

Once you're on birth control and you're sexually active, would you not welcome a practice that spots potential issues that accompany it, like STDs? Having a regular exam when you're sexually active gives you a professional you can regularly ask questions about your body and what you're doing, which was VERY helpful to me, as a young person having sex. I was never treated like some dirty woman with a vagina just waiting to be filled with disease. That said, when I did have a sexual health issue, the doctor caught it early and took care of it, for which I am thankful.

Maybe I've just been lucky, but I have been to a handful of different doctors in my time, and while I did like some more than others, I haven't ever heard of anyone I know feeling like this. I am interested to hear more about it.

[frolicnaked.livejournal.com]

Once you're on birth control and you're sexually active, would you not welcome a practice that spots potential issues that accompany it, like STDs? Having a regular exam when you're sexually active gives you a professional you can regularly ask questions about your body and what you're doing...

Certainly, but neither of these things are syonymous with bimanual pelvic exams. STDs can be tested for via urine or blood tests -- And even a vaginal swab is sometimes decidedly less time consuming and painful than is a bimanual exam. And asking patients should be able to ask questions of their health care providers regardless of whether that provider's hands have been in the patient's vagina. ;)

[misspaigeb.livejournal.com]

THIS is exactly what makes me feel so uncomfortable about getting those exams. I feel like it's all about power and control and compliance than my actual health. Not to mention, putting yourself in a vulnerable position with someone you hardly know and then the possibility that you could get a shitty doctor who feels the need to shame you about your sexual practices.

And while the new NP I saw last last summer didn't push a pap smear on me (I couldn't pay for it at the time, and was definitely not coming back just for that when it gives me so much anxiety) she pretty much insisted on looking at my cervix with a speculum for "lesions." I am 20 years old. I just don't appreciate being made feel like I have something wrong with me because I have a vagina. I do like going in for the appointment and discussing everything with a medical professional when I get my birth control prescription, it's the unnecessary exams and feeling like I can't stand up for myself against intimidating doctors that is so bothersome.

[frolicnaked.livejournal.com]

Bimanual exams can sometimes detect early stages of endometriosis...

I'd very much like to see stats on this. I've had what I believe is symptomatic endometriosis for 16 years (diagnosed 2 years ago, but have had the same symptoms since menarche). I've never had a provider suggest endo to me based on the results of bimanual exams (which I started getting when I was 15 or so). More than that, when I've spoken to health care professionals specifically about endo, they've all said that catching endo via bimanual exam is basically an infrequent and unlikely fluke -- for someone who's symptomatic. For someone who's experiencing no symptoms (since that's basically who the articles are discussing), I don't even know what the figures would be.

[paraxeni.livejournal.com]

As you know our history is very similar. Symptoms of endo since menarche, first bimanual at 19 (related to my PCOS) with others after that, and it took till I was 27 to get a diagnosis. Of course by then, the deposits were visible on xray due to their size. My surgeon said he prefers not to do bimanuals on people he suspects have endo until he's seen evidence (via scans) that doing so would not harm or traumatise his patient. He said the thought of manually examining someone who may have deposits in... oh what's it called, you know, around the base of the uterus above where the cul-de-sac is? Anyway, he claims it's brutal and needlessly invasive as well as pointless. You and I both know that microscopic deposits can cause unbearable pain, and they're virtually indetectable. Trying to diagnose endo with a manual exam is a bit like trying to decorate your house through the letterbox!

[rebeccagrace.livejournal.com]

Considering my first pelvic was done for no other reason than I wanted to be on birth control and it was extremely traumatic and painful, I wish I had read this and went to another doctor.

[queensugar.livejournal.com]

One of the big things I have seen, via this community and elsewhere, that really sits poorly with me is the concept of beginning pelvic exams (not necessarily pap tests) at relatively young ages, in order to, if I may quote, "make sure everything is alright down there."

This perspective isn't common where I am, so it downright shocked me seven or eight years ago when I started interacting online with people, especially those in the U.S., about reproductive and sexual health. And I find it very uncomfortable, as there is a definite sort of paternalism that's built into that, this reinforcing fear tactic that there could be something "wrong with you" and you'd never even know it.

While that can be true, I find it blows reproductive issues a little... well, out of proportion. And it creates a culture of fear of the reproductive system that I think can be terribly disempowering and harmful to people.

I'll put it this way: I get, say, listening to the heartbeat as part of a regular check-up, or taking blood pressure. That's because A) it's non-invasive and B) if I'm not mistaken, both heartbeat and blood pressure can yield evidence of certain health conditions that may be relatively asymptomatic or undetected.

But as this evidence and much else demonstrates, the same really isn't true of routine pelvic exams. I'm never sure what exactly people mean when they talk about taking people in their mid-teens, including those who aren't yet sexually active, for a pelvic exam to "make sure everything's alright down there." What wouldn't be alright, but also largely asymptomatic and health-relevant? There never seems to be an answer for that.

It seems too a lot of that fear is tied up with fertility, which again I find problematic, since it sort of reinforces this fear that anything could be wrong with your fertility at any time, and that this is something to be terrified of, even if you're nowhere near a point where you might be considering becoming pregnant and thus nowhere near a point where you'd want to start researching the many options to treat fertility problems, and that a pelvic exam can even diagnose that, which it can't.

Overall I don't think it's a very empowering message, and I think if anything it quietly discourages people growing into a sense of autonomy and understanding of their own reproductive systems. It seems like it's the product and driver of a culture which reinforces people being afraid of their reproductive organs, as if they are primed to "go wrong" at any moment.

What I'd much rather see is more education about self-exploration and bodily awareness. I'd rather see teens in the U.S. taught how to explore and identify their own bodies and how to seek appropriate care for any symptoms that do crop up. That would be a much more empowering and educational approach to take, I think, than establishing this reliance on doctors to tell you whether or not "everything's alright down there."

[queensugar.livejournal.com]

Oh, and I think the whole medicalization of the normal reproductive system can really be seen reflected in how often people express a sense of extreme urgency about scheduling a "gyno" appointment in the event of almost any mildly errant reproductive symptoms for themselves that aren't suggestive or consistent with an urgent issue.

One example -- it always amazes me how many people I talk to who are scheduling an appointment for a doctor visit and/or pelvic exam because their period is, say, a week late and pregnancy is ruled out, and how fearful they are of "what could be wrong."

Meanwhile, it's clear that if pregnancy is ruled out, there's really no need to see a doctor for a period that's only a week late -- that this is a very minor and non-concerning variation even for people with the most regular cycles.

I appreciate that it makes many people feel relieved or more comfortable to have it "checked out," but I can't help but wonder if we didn't set up the system for them to feel stressed out by it in the first place by emphasizing routine medical "monitoring" of the reproductive system. And I can't help but think that if we were doing a better job at teaching broader knowledge about the reproductive system, and personal empowerment, that we might both save people money (if it costs them to see a doctor) and a lot of stress and fear of their own reproductive systems.

[deeplyunhip.livejournal.com]

I agree that this is a sad practice when there's no big connection (my first pelvic exam was before I had lost my virginity and it was a freaking nightmare), but I'm rather upset that none of these articles have any suggestions or recommendations about the few places in the U.S. that might let you get birth control without exams. Even Planned Parenthood makes you have exams, at least here in New York. It's nice that someone's pointing out the problem, but I'd really like to be able to actually find a place to go that doesn't demand a yearly exam. :/

[marionravenwood.livejournal.com]

Yeah--as I said, I was surprised at the study from my third link stating that 16-49 percent of providers always required an exam: I would expect in actual practice the numbers are much higher. However, the takeaway from that study is that advanced-practice nurses specializing in women's health were the least likely to require a pelvic exam, so maybe start there?

Or you could consider Washington D.C, if this passes
http://www.nbcwashington.com/news/politics/DC--Bill-to-Ease-Access-to-Birth-Control-Introduced-116310539.html?dr

I can tell you right now that if I needed birth control I would almost certainly just order it off the internet. Why should I put up with what will likely be bad treatment from healthcare providers?

[hellokitten.livejournal.com]

When I was on HBC I had to have an exam/pap or no new prescription. This is spanning several years and different doctors. It's been a requirement with each of them. I honestly never questioned it before reading this - that there were places or providers that didn't require it. :/

I'm a medical coder and I can attest to the pelvic exam/pap = more $ (in the US at least).

[jennifer0246.livejournal.com]

I wonder if there really are so many health care providers themselves who are requiring a pelvic exam visit be scheduled, or if that's a misconception of office staff (schedulers, assistants, and the like). The office I worked at most recently had many providers, and none of them insisted on physical exam, though if a patient called to book an appointment "for birth control", that would be booked as an "annual" exam and the patient would be told to expect to need to remove pants to have that exam.

I think there's also a great deal of misconception as to what terms like "pelvic exam" and "pap smear" mean. Many, many people believe that if you go to a "gynecologist" (or really any HCP who provides services dealing with vaginas) you must have a "pap smear" which tests you for every kind of infection and cancer known to man. And uh ... none of that is true, so.

[marionravenwood.livejournal.com]

I think there's also a great deal of misconception as to what terms like "pelvic exam" and "pap smear" mean. Many, many people believe that if you go to a "gynecologist" (or really any HCP who provides services dealing with vaginas) you must have a "pap smear" which tests you for every kind of infection and cancer known to man. And uh ... none of that is true, so.

Yes, absolutely, and in my opinion that is yet another drawback to pelvic exams: how many times have people ignored pain or problems because they believe that their gynecologist would have found "anything," during a pelvic exam?

While I believe patients share some of the responsibility for this problem by just going along with pelvic exams without finding out what they're for or getting pap tests too early or too often, I also think that healthcare providers really, really need to take more responsibility for informed consent in so-called well-woman care: patients must be told of exactly what pelvic exams and pap tests do and do not do. I would even go so far as to say that informed consent is pretty much ignored in any meaningful sense. People are told they "have to" have pelvic exams or pap tests, without any mention of potential drawbacks or why they might not want to have them. In many instances patients are bullied and shamed into it.

I wonder if there really are so many health care providers themselves who are requiring a pelvic exam visit be scheduled, or if that's a misconception of office staff (schedulers, assistants, and the like). The office I worked at most recently had many providers, and none of them insisted on physical exam, though if a patient called to book an appointment "for birth control", that would be booked as an "annual" exam and the patient would be told to expect to need to remove pants to have that exam.

If that is the case, how can that be fixed?

[eliz52.livejournal.com]

I'm so pleased the truth is finally emerging in the States. The routine pelvic exam is of poor clinical value in asymptomatic women and exposes you to risk (more unnecessary and possibly harmful procedures and even surgery)
It's also an exam at the top end of invasive and should only be done when absolutely necessary - there is even research that says the pelvic exam is not all that helpful in symptomatic women and that ultrasound and CAT scan are more reliable.
I find it so dishonest to hear American doctors urging women to have this "VERY, VERY important life-saving exam every year". What is their agenda? This comment was made by a Dr on "The Doctors" program recently.
There are lots of medical journal articles that discuss this topic and they all agree - unhelpful and risky in healthy women. I've never had a routine pelvic exam and never will...
Routine breast exams are not recommended here either - they don't bring down the death rate, but cause biopsies. I'm breast aware - taking note of the look and shape of my breasts in the mirror every morning after showering.

Rectal exams and visual inspections in symptom-free women - too ridiculous for words! I don't have them...
Pap tests have been over-used and used inappropriately in many countries causing great harm and distress, but the States is the worst for excess.
95% of you will be referred to cover a lifetime risk of cervical cancer that is less than 1%. That is huge over-detection.
Testing women under 30 doesn't help them, but exposes them to lots of risk - 1 in 3 tests will be "abnormal" - the pap picks up normal changes in the maturing cervix or transient HPV infections - this results in lots of harmful over-treatments like LEEP and conizations - these procedures carry the most risk and can damage the cervix causing - cervical stenosis (that can lead to endometriosis, infections and may require surgery if the cervix is scarred shut), infertility, also, cervical incompetence - miscarriages, high risk pregnancy, premature babies and c-sections plus psych issues. The 1 in 3 may be even higher in the States as that figure is based on a UK study that examined the consequences of 3 yearly testing in women under 25.(Dr Raffle's research) Testing does not change the tiny death rate in women under 30 ("Cervical cancer screening" by Assoc Prof Margaret Davy and Dr Shorne in "Australian Doctor" 2006 - on line)
The very rare case in a woman under 30 tends to be missed by the pap test and these women get false negatives, probably because the cancer is usually a adenocarcinoma and the pap is bad at detecting that very rare type of cervical cancer.

As a low risk woman, my risk of cc is near zero - yet like most women I was told I should or must have screening - and wasn't told our program carried a 77% lifetime risk of referral. I got those answers for myself and have always declined screening. (See: Kavanagh and others - research on "Lifetime risk of colposcopy in cervical screening" - also cited by Dr Laura Koutsky in her article on the same topic in Cancer Prevention, Fall 2004, Issue 4)
I'd urge every woman to examine her own risk profile and make informed decisions about cancer screening.

Mammograms - I've also declined them due to concerns about risk - false positives and over-diagnosis. Fortunately, the Nordic Cochrane Institute have produced an unbiased summary for us - they were so concerned at the "information" being released to women with glaring omissions and misstatements - "The Risks and benefits of mammograms" appears at their website. Also, read anything by Professor Michael Baum, UK breast cancer surgeon.

See: Dr Joel Sherman's article, "Informed consent is missing from cervical screening" - also, Dr Joel Sherman's medical privacy forum and under women's privacy concerns - in the side bar - you'll find some great references - the actual facts!
Blogcritics and unnecessary pap smears has around 3600 posts from women concerned at the lack of respect for informed consent in women's health care.
Good luck everyone...

[eliz52.livejournal.com]

One final point: for women who want to have cervical screening, the safest program (as far as possible with this intrinsically unreliable test) is the Finnish and Dutch program.
Finland has the lowest cc rates in the world and just as importantly sends the fewest women for colposcopy/ biopsies (fewer false positives) - they offer 5 to 7 tests in total - 5 yearly from age 30.
This program sends 35%-55% of women for colposcopy/biopsies at some stage - still high for such a small risk, but a lot better than 95% (the States) or 77% (Australia) or 65% (UK)
In the States some older women have had more than 45 pap tests...