February 25, 2020 01:49 pm Michael Devitt -- More than half of pelvic examinations and almost three-quarters of Pap tests performed in teen girls and young women may be unnecessary, potentially exposing them to preventable harms and generating considerable costs. That's according to the results of an investigation published online last month in JAMA Internal Medicine that examined the prevalence of use of these tests in patients with no medical indication.
"The American College of Obstetricians and Gynecologists recognizes that no evidence supports routine speculum examination or bimanual pelvic examination in healthy asymptomatic women younger than 21 years and recommends that these examinations be performed only when medically indicated," the authors wrote. "Our results showed that despite the recommendation, many young women without discernable medical indication received potentially unnecessary BPE or Pap tests, which may be a reflection of a longstanding clinical practice in the United States."
For its part, the AAFP recommends against screening pelvic exams in asymptomatic women regardless of age. That stance differs from that of the USPSTF, which in its 2017 final recommendation statement found insufficient evidence to assess the balance of benefits and harms of performing screening pelvic exams in asymptomatic, nonpregnant adult women "for the early detection and treatment of a range of gynecologic conditions."
The researchers analyzed responses from a representative sample of 3,410 adolescent girls and young women ages 15 to 20 from the National Survey of Family Growth from September 2011 to September 2017. Among other things, the survey asked participants whether, in the past 12 months, they had received a bimanual pelvic exam (with the question phrased to emphasize the bimanual component of the exam) or a Pap test.
Women who answered yes to either question were asked if they underwent the exam or test as part of a routine exam, because of a medical problem, or for some other reason. They also were asked if the pelvic exam was performed at the same visit as the Pap test.
The investigators classified pelvic exams as being medically indicated if, in the past 12 months, a patient was pregnant; had used an IUD; had a medical condition or other reason that indicated a pelvic exam should be performed; or had received treatment for chlamydia, gonorrhea, syphilis or genital herpes.
If a woman received a pelvic exam but did not have one of these indications, the exam was classified as potentially unnecessary.
Based on their analysis, the researchers estimated that almost 2.6 million teen girls and young women had received a bimanual pelvic exam in the previous 12 months. Of those, more than 54% -- about 1.4 million -- were considered potentially unnecessary.
During that same period, about 2.2 million teens and young women received a Pap test, and the researchers considered nearly 72% of those procedures potentially unnecessary.
In addition, almost 98% of potentially unnecessary BPEs were performed during the same visit in which a Pap test was performed.
The authors used Medicare payment data for 2014 to estimate that the potentially unnecessary procedures cost more than $123 million in one year.
"These findings suggest the need for education for health care professionals, parents and young women themselves to improve awareness of professional guidelines and the limitations and harms of routine pelvic examination and Pap test and to ensure that these tests and examinations are performed only when medically necessary among young women," the researchers concluded.
"The findings … demonstrate what happens to vulnerable populations (in this case, girls and young women) when clinicians do not keep up with or do not adhere to new guidelines," said Melissa Simon, M.D., M.P.H., vice chair for clinical research in the Department of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine in Chicago and a co-author of the USPSTF's 2017 final recommendation statement in an accompanying commentary.
Study co-author George Sawaya, M.D., a professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco, told AAFP News that it can be difficult for physicians to stay up to date with the latest guidelines.
"Keeping up with the latest recommendations is a challenge, especially when there are several professional groups publishing guidelines at different times," Sawaya said. "Clinicians can typically rely on their own specialty society to provide evidence-based guidance on common clinical questions. As an example, the American College of Obstetricians and Gynecologists began discouraging cervical cancer screening in women and girls under age 21 back in 2009."
It's important to note that the AAFP's clinical preventive service recommendation clearly states there is evidence of harms from performing screening pelvic exams in asymptomatic women based on the associated increased risk of invasive testing and unnecessary treatment.
Other harms aren't as easily perceived. Sawaya addressed the implications such an experience could have on young women and emphasizing the importance of talking with patients beforehand.
"Fear of getting a bimanual pelvic examination may cause young girls and women to not seek important preventive care, such as birth control or screening for sexually transmissible infections," he said. "Educating asymptomatic girls and women about what to expect from a clinic visit may help assuage fears, especially if it is made clear that a bimanual pelvic examination will not need to be performed."
Overall, he continued, "Clinicians can go a long way in fostering a sense of a shared mission with patients in terms of preventing adverse health consequences of undiagnosed and untreated cervical infections such as ectopic pregnancies, infertility and chronic pelvic pain." Although a bimanual pelvic exam can yield useful information in patients who display symptoms such as pelvic pain or abnormal discharge, options exist for other types of screening.
"Cervical cancer screening requires a speculum exam, but STI screening may be done with urine-based tests, obviating the need for a speculum examination," he said.
In many instances, shared decision-making between clinicians and patients can illuminate the best course of action.
"When there is a decision to be made for which the benefits and harms are well known and quantified, shared decision-making can be appropriate," said Sawaya. "The benefits of bimanual pelvic examinations in asymptomatic individuals are unknown, but the harms include false-positive testing and invasive procedures.
"It is difficult to have shared decision-making about benefits and harms when the benefit part of the equation is unknown."