Are your periods regular?
Do you have any unusual pain or discomfort?
What medical problems do other members of your family have?
These are just some of the questions young women may be asked at their annual wellness exam. They may also receive an unnecessary pelvic exam, according to a new study published in JAMA Internal Medicine.
The researchers found that almost one-quarter, or 2.6 million, young women between the ages of 15 and 20 received a bimanual pelvic exam — during which a doctor places two fingers inside the patient’s vagina to check for abnormalities in the uterus or ovaries. More than half of those exams were potentially unnecessary.
As for the Pap test, a type of speculum exam where the doctor looks at the patient’s cervix and takes a cervical cell sample, three out of four young women received the test when they did not need to.
The current recommendations for pelvic exams set forth by the American College of Gynecology are to do the first Pap test at age 21 for women who are asymptomatic, or not showing signs or symptoms of an infection or disease. If that test comes back normal, doctors can wait three years to perform the test again.
But with pelvic exams, there’s really no need to perform one if the woman is asymptomatic, said Maryam Guiahi, an OB-GYN and researcher at the CU School of Medicine.
Ten years ago, Guiahi co-authored a study that had a similar message: pelvic exams may become obsolete with the advent of emerging technologies such as urine tests for STIs and self-administered vaginal swabs to test for HPV, which can cause cervical cancer. And yet, routine pelvic exams in asymptomatic women under the age of 21 are still happening.
“It has a lot to do with when these providers got their training, people tend to stick with what they learned back in their residency and if that was 10, 20 years ago, they may still just be kind of doing that,” Guiahi said.
The exam can be scary and uncomfortable for some patients, and may even result in them avoiding visiting the gynecologist out of fear.
“The reality is that doing a routine exam on an asymptomatic woman not only puts her in an uncomfortable position, literally, but it also often leads to unnecessary tests,” Guiahi said. “So a provider might feel around and then think, 'Oh, maybe her uterus is a little bit bigger,' and then get an ultrasound.”
That ultrasound can lead to a biopsy or other tests that, according to one systematic review, may not reduce the number of women who get sick or die from the conditions these tests are supposed to screen for. The exception is cervical cancer, and in that case only a visual inspection and Pap test are required.
There are also implications for the healthcare costs associated with unnecessary tests. The study authors found that all those potentially unnecessary pelvic exams may cost more than $123 million a year, and that’s using Medicare payment figures from 2014.
For patients, the exams are often associated with fear, anxiety, embarrassment, discomfort, and pain. Guiahi said one way to destigmatize the appointment, aside from performing it according to the guidelines and after a conversation with the patient, is to provide better sex education.
“With comprehensive sex education programs, we can educate women about their bodies,” Guiahi said. “We can educate women about consent during intercourse and we can educate them about what to expect from an OB-GYN. What should they be? Why would, what would be the reasons to go to an OB-GYN and what should they expect.”