Millions of unnecessary pelvic exams and Pap tests have been performed in women prior to the U.S. recommended screening age of 21, despite concerns of adverse effects

A study published in the Journal of the American Medical Association found that 54.4% of pelvic exams and 71.9% of Pap smears conducted in teen girls in the U.S. are potentially unnecessary and may expose women to preventable harm.[i]

While it’s clear that pelvic exams are an important screening procedure for cervical cancer, the U.S. Preventive Services Task Force (USPSTF) and the American Cancer Society both recommend that these screenings do not take place before the age of 21 unless a patient has symptoms of cervical cancer.[ii],[iii]

Yet many gynecologists continue to perform these exams at yearly wellness exams in asymptomatic patients, despite increased reports of anxiety, pain and feelings of disempowerment in women who undergo these examinations.

Pap Tests and Pelvic Exams

A bimanual pelvic exam (BPE) is a physical examination of outer and inner female reproductive and urinary organs. Papanicolaou tests (or Pap smears) are diagnostic procedures used to screen for cervical cancer.

In the U.S., pelvic exams and Pap tests are recommended annual procedures after the age of 21, while in other countries, the tests are performed far less frequently and in a less invasive manner, with similar prevention rates and fewer side effects.[iv]

During a bimanual pelvic exam, a doctor uses lubricated, gloved fingers inserted into the vagina to examine the size and shape of the uterus, and uses a speculum to observe the vaginal walls and cervix. If conducting a Pap test, the doctor swabs the cervix to collect cervical cells for testing.

The examination typically takes less than 10 minutes, but many women find the experience uncomfortable or painful. Additional adverse effects linked to BPE and Pap tests include:

Increased urinary frequency the month following an exam

Emotional distress

Dysuria (pain or discomfort when urinating)[v]

Fear of pain

Urinary tract infections, which are more likely in the seven weeks following a Pap smear[vi]

Vaginisms (painful spasms of the vaginal muscles)[vii]

Unnecessary medical costs

Overdiagnoses[viii]

Anxiety

Both types of exams are invasive and becoming controversial as women increasingly report feeling disempowered or anxious before and during the procedures. Yet despite the prevalence of these adverse effects and the ability to screen using alternative methods, the default decision is often to screen via pelvic examination.[ix]

Unnecessary Exams in Elderly and Post-Hysterectomy Women

Similar studies have found a high rate of unnecessary pelvic examinations among elderly women who may have erroneous beliefs about the purposes of the exam.[x] Other studies confirm that many women who have had hysterectomies have unnecessary Pap smears, despite recommendations from the USPSTF to avoid screening women with hysterectomies who have no history of cervical cancer.[xi],[xii]

In a study of all women receiving Pap smears, researchers concluded that lack of education around recommended screening ages or necessity of the procedure may partially drive these clinically unnecessary examinations:

"We conclude that women may potentially receive Pap tests even if they are not at risk for cervical cancer, and may not be adequately informed about the need for screenings. We recommend strategies to disseminate recommendations and information to patients, their families, and care providers."[xiii]

Pelvic Exams Performed Without Consent

In 2011, an American medical student named Shawn Barnes in his third year of medical school was shocked when his medical trainers instructed him to perform unauthorized pelvic exams on anesthetized and unconscious women. For Barnes, it was a moral and ethical dilemma, and he went on to write a paper exposing the practice.[xiv]

While the practice is now illegal in Hawaii, California, Illinois, Virginia and Oregon, this medical training is still practiced in the remaining states and is covered in detail in the film "At Your Cervix," a documentary exposing the disrespectful and disempowering practice.

Lack of Educations Leads to Unnecessary Examinations

Researchers believe the problems lie in a lack of education among women and practitioners. Many women are unaware that pelvic exams are not recommended after the age of 65, after a hysterectomy or before the age of 21.

In fact, the U.S. guidelines recommend exams every three years between the ages of 21 and 30, yet the majority of women continue to have annual Pap smears and pelvic examinations long after the age of 30, despite a lack of qualifying symptoms, because they believe yearly exams reduce cervical cancer mortality.[xv],[xvi],[xvii]

Additionally, physicians continue with the practice even in asymptomatic patients, although there are other ways to test for vaginitis and sexually transmitted diseases, such as urine tests and vaginal swabs (pelvic exams are still necessary for diagnosing pelvic inflammatory disease.)[xviii]

Yet feelings of disempowerment or anxiety are prevalent during these exams, and physicians who do not adhere to national guidelines are putting vulnerable populations at risk. Protection of patients’ rights, better education around the purpose and necessity of pelvic exams, and clearer consent forms are needed to provide sexual empowerment to women in the examination room.

References

[i] JAMA Intern Med. Published online January 6, 2020

[ii] American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2019-2020. Atlanta, Ga: American Cancer Society; 2019.

[iii] Draft Recommendation Statement: Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 2018.

[iv] Int J Cancer. 2017 Mar 1; 140(5): 1215–1222.

[v] J Am Board Fam Med. 2011 May-Jun;24(3):290-5. doi: 10.3122/jabfm.2011.03.100209.

[vi] J Am Board Fam Med. 2011 May-Jun;24(3):296-303. doi: 10.3122/jabfm.2011.03.110009.

[vii] J Gen Intern Med. 2011 Jun; 26(6): 651–657.

[viii] JAMA Intern Med. Published online January 6, 2020. doi:10.1001/jamainternmed.2019.5727

[ix] Millions of Unnecessary Teen Pelvic Exams, Pap Tests Performed

[x] Womens Health Issues. 2007 Nov-Dec;17(6):351-9. Epub 2007 Oct 22.

[xi] Draft Recommendation Statement: Cervical Cancer: Screening. U.S. Preventive Services Task Force. August 2018.

[xii] Am J Public Health. 2016 November; 106(11): 2005–2011.

[xiii] J Prev Med Public Health. 2018 Jul; 51(4): 181–187.

[xiv] Obstet Gynecol. 2012 Oct;120(4):941-3.

[xv] J Gen Intern Med. 2004 Mar; 19(3): 243–250.

[xvi] The American Cancer Society Cervical Cancer Screening Guidelines

[xvii] Ann Fam Med. 2003 Nov; 1(4): 203–208.

[xviii] J Pediatr Adolesc Gynecol. 2003 Feb;16(1):25-30.

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