For a young woman, a checkup at the gynecologist may consist of several components: discussing her sexual and reproductive history, checking her breasts for lumps, getting tested for sexually transmitted infections. But in many cases, pelvic examinations — in which doctors insert two fingers into the vagina to inspect irregularities in the uterus or ovaries — may be unnecessary, according to new research.
In 2012, the American College of Obstetricians and Gynecologists (ACOG) concluded that pelvic exams weren’t generally recommended for individuals under 21. The recent study, published Monday in JAMA Internal Medicine, found that more than half of the bimanual pelvic exams conducted from 2011 to 2017 among U.S. women aged 15 to 20 were “potentially unnecessary.” The research also found an estimated 2.2 million women aged 15 to 20 (19.2 percent) received a Pap smear test in the past 12 months, and 71.9 percent of those tests were potentially unnecessary. The analysis was based on National Survey of Family Growth data from 2011 to 2017 from 3,410 young women.
The study authors wrote that pelvic exams “may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs.” As NBC News reports, the study authors said it’s unclear why so many young women appear to be undergoing manual examinations, but that “it is likely habit from outdated OB/GYN practices.” The authors were also “concerned about reports of criminal misconduct, such as the cases against former Olympic gymnastics team doctor Larry Nassar, as well as complaints about a gynecologist at the University of Southern California,” NBC reports.
In light of the news, we asked several OB/GYNs to weigh in on the research and offer their advice to young women.
Answers have been lightly edited for length and clarity.
“We are at a point in time where we need to do everything we can to improve women’s health, women’s health literacy and the state of reproductive health care. To that end, we should be not only practicing clinical gynecology at the highest level, but we should be remembering the Hippocratic oath of, ‘First, do no harm.’ By performing routine pelvic exams on adolescents, many of whom are virginal, we run the very real risk of doing emotional and physical harm — and all for something that has very limited clinical value in this age group, especially in teens without symptoms. If we inadvertently wind up sending a message to teenage girls that a trip to the gynecologist is something to dread, we not only jeopardize their short-term health, but potentially a lifetime of women’s health and wellness, too.
It is time we reevaluate this routine practice — not just for teens but also for adult women without symptoms, and ask ourselves not only why we should do a test, but why we shouldn’t do that test. Individualize medical care and think before we just act.
I have been in practice for 15 years, and half of my patients are under the age of 21. It has been my practice from the beginning, in keeping with ACOG guidelines, not to perform routine pelvic exams on my adolescent patients, even if they are sexually active. And I think this provides benefits that outweigh any risks.”
Jennifer Ashton is the chief medical correspondent at ABC News and an OB/GYN practicing in Englewood, N.J.
“There’s a lot of ignorance, misinformation, about pelvic anatomy — what ‘normal’ anatomy consists of. What I do when I’m examining a young woman is point out to her what’s going on with her anatomy. What her vulva is, where her urethra is. Whether you have to do an internal bimanual examination, that may be a different story, but certainly examining her in some part might be very helpful. A lot of kids just want to know, ‘Am I normal?’ And sometimes an exam is what’s needed to say, yes, you’re normal. What’s part of it is that so many young women wax these days. So there are so many young women looking at each other’s anatomy — there’s so much comparison and so much confusion.
Now, if someone is having unprotected sex, you have to do whatever STD screening is appropriate, whether that’s a vaginal exam or a urine specimen. As far as internal exams, people do do exams of the cervix — a culture of the cervix to check for gonorrhea and chlamydia, for example.
One thing that we do try to point out is that endometriosis can occur in very young women. Granted, a pelvic exam is not the be-all and end-all of diagnostic tests, but it can give you some idea of what’s going on. So if someone is having significant pain, doing an internal exam is probably a good idea. We certainly don’t want young women to think we’re dismissive of their pain.
In general, I think young women should see someone that they can speak with, that they know is going to listen to them and give them guidance in a nonjudgmental manner. I’m a big advocate of trying to have a good relationship with your gynecological health-care provider, be that a gynecologist, be that a nurse practitioner, a midwife or your primary-care provider.”
Mary Jane Minkin is a clinical professor of obstetrics and gynecology at Yale University School of Medicine.
“The new study does not surprise me. Best practices in medicine are always evolving, and it’s critical that we shift care given the latest research in all areas of medicine. Patients, no matter their age, should always be empowered to know why they’re receiving a certain medical procedure. The patient-provider relationship is built first and foremost on trust; if young patients are feeling violated, then we as health-care providers have to be doing more to have open and honest conversations with our patients.”
Stephanie Ho is a fellow with Physicians for Reproductive Health and a family medicine physician in Arkansas.
“The American College of Obstetricians and Gynecologists recommends that the initial health visit be between the ages of 13 to 15 years. That does not mean an exam is needed. In fact, if someone is having no symptoms or concerns and is just presenting for a wellness exam and no findings are learned of during the history, an exam is unlikely to be done.
Before an adolescent sees an OB/GYN, it is best to make sure that the OB/GYN is comfortable providing appropriate and adequate care to adolescents.
During the initial reproductive health visit, we strive to give preventive health care, including guidance and educational material — that can help alleviate fears and develop a sense of trust. We can discuss family history, medical history and initiate normal conversations about puberty, menstruation, sexual activity and any other concerns that one may have.
A general exam can typically include an inspection of the breasts and external genitalia. An internal exam is usually not done at an initial visit unless there are problems discussed. For example: abnormal bleeding, discharge, pain.
For women who may want to consider an intrauterine device for birth control, it is helpful to do a pelvic exam and assess if they may tolerate that form of birth control.
A Pap smear is not needed until the age of 21 years old. So, if a woman is less than 21 and has no concerns or problems or no desire for an intrauterine device, she most likely does not need an internal pelvic exam. She does, however, need to establish care before the age of 21 as per the recommendations of the ACOG.”
Christine Greeves is an OB/GYN surgeon at Winnie Palmer Hospital for Women and Babies in Orlando.
“The unnecessary performance of pelvic exams for any reason is unacceptable in medical care. As the study notes, there are likely many reasons this happens, including outdated clinical practice that historically tied accessing birth control to a physical exam and the medically unnecessary state requirements around safe, legal abortion we’ve seen in Missouri. As a provider, I know that pelvic exams are invasive and intimate for patients — and the decision to perform an exam should be shared between a patient and their provider. This study demonstrates an urgent need to educate both the public and providers on a more patient-centered approach to reproductive health care.”
Colleen McNicholas is chief medical officer at the Planned Parenthood of the St. Louis Region and Southwest Missouri.
“At Sanford Health, we know that the science of medicine continues to evolve, so the practice of medicine must also evolve. Historical practice patterns can be difficult to change. I was trained that once someone became sexually active, they needed to have a Pap smear. We now know that is not the case. In order to ensure that all of our physicians are modifying their practice to meet this new knowledge, we leverage our electronic medical record. For example, if a physician orders a Pap smear and performs a pelvic exam on a patient under age 21, the electronic record will immediately show an alert saying this isn’t recommended, and then explain why. The beauty of the electronic medical record is that it allows us to disseminate evidence-based medicine in the moment, to educate both physicians and patients. It is one thing to read an article about the new evidence and how to modify your practice, it is another to be nudged to change your practice with the patient in the exam room. If we identify physicians who are not modifying their practice, we have one-on-one conversations with them to help them understand the evidence. When we reduce unnecessary tests, our physicians can focus on what matters for our patients, be good stewards of the health-care dollar and prevent unnecessary harm to our patients.”
Allison Suttle is chief medical officer for Sanford Health, the nation’s largest rural nonprofit health-care system.