Are Doctors’ Exams a Barrier to Birth Control?

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Physicians usually require an annual pelvic exam before prescribing oral birth control to women, but the two practices have no medical reason to be linked. Indeed, according to a consortium of health-care providers and researchers, called Oral Contraceptives Over-the-Counter Working Group (OC-OTC), the annual pelvic exam is still a major barrier to access to contraception for many American women.

The OC-OTC points to a recent survey conducted by researchers from the University of California, San Francisco, which found that about one-third of 1,200 doctors surveyed always required a pelvic exam before writing a prescription for birth control pills, and 44% “regularly” required the exam. (More on Study: Does the Pill Lower Sex Drive?)

The survey, published in the journal Obstetrics & Gynecology, found that family doctors were slightly more likely than OB-GYNs to require the exam (33% versus 29%); older doctors were also more likely to insist on the exam than younger doctors, as were doctors whose patients included low-income women who used Medicaid.

“The survey of clinicians about pelvic exams isn’t really surprising, but it’s one more piece of information documenting the barriers that the medical community imposes on access to contraception — barriers that are not supported by evidence,” said OC-OTC member Dr. Daniel Grossman, who is also a senior researcher at Ibis Reproductive Health in San Francisco. (More on Are You Fertile? Don’t Rely on a Drug-Store Fertility Test to Tell You)

The annual pelvic exam is important for screening for sexually transmitted infections, ovarian cysts, cervical cancer and other health problems, and it is a critical part of routine care for women. But it has no bearing on whether a woman should be prescribed oral contraception. And in many cases — because of scheduling problems or resistance to seeing a doctor — the exam prevents or delays women from getting birth control.

Reuters recently reported:

There is no established medical need for women to have the exam before receiving a prescription for birth control pills, [Dr. George F. Sawaya, one of the researchers on the study,] said. It’s just that, traditionally, pelvic exams have been coupled with contraceptive prescriptions; in many cases, it may have simply been convenient for women to have a pelvic exam as part of their routine healthcare at the same time they were seeking a birth-control prescription.

“The two just became linked,” [Dr. Andrew M. Kaunitz, an OB-GYN not involved in the study,] agreed. But while there is nothing wrong with that, he said, “women also deserve the option of un-linking those two services.”

The World Health Organization and the American College of Obstetricians and Gynecologists (ACOG) recently changed their guidelines to reflect the distinction between annual check-ups and pregnancy avoidance: neither organization now requires a pelvic exam in advance of birth control prescriptions. (More on Is Birth Control Preventive Medicine?)

Although there is no official recommendation for how often women should have pelvic exams, the ACOG does have guidelines for Pap smears, a cervical-cancer screen that is typically done during the annual pelvic exam. The ACOG advises Pap smears every two years from the age of 21; after the age of 30, women who have had three negative Pap smears may be screened once every three years. As Reuters reported:

Along with added costs, unneeded pelvic exams also open women up to the possibility of having an abnormal finding that, upon further testing, turns out to be nothing. “Any (test) we do with an asymptomatic person has a chance of resulting in a false-positive,” Sawaya pointed out.

If your doctor insists on a pelvic exam before prescribing birth control, it’s fair to ask why.  Certainly the exam is important and there may be a medical need, but as the new study suggests, requiring one for the purposes of birth control is just habit, and isn’t based on science.

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