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Am Fam Physician. 2002;65(1):124-126

A commonly accepted practice is to require clinical breast and pelvic examinations before beginning the use of hormonal contraceptives. Stewart and associates reviewed and summarized the published literature and recommendations from professional organizations regarding the role of clinical breast and pelvic examinations before use of hormonal contraceptives.

Major organizations in the field were contacted, and consensus statements, policy statements, and review articles were identified through a review of current literature. In the past seven years, expert medical opinion has shifted from requiring breast and pelvic examinations before the initiation of hormonal contraception to merely encouraging these examinations as a part of routine care. This shift has been based on results of various studies. One study showed that more than one fourth of teenagers who had the choice to defer the pelvic examination did so, with almost 80 percent returning within six months for follow-up. Those who deferred the examination were more likely to use condoms and less likely to become pregnant, and had similar sexually transmitted disease (STD) rates as those who had the examination before initiation of hormonal contraception.

Other studies showed that pre-prescription examination requirements decrease access to hormonal contraception by causing women to believe that contraceptives are more dangerous than evidence supports. Hormonal contraceptives might then be more likely to be used inconsistently or discontinued prematurely. Requiring breast and pelvic examinations before dispensing hormonal contraceptives may be seen as coercive.

There has also been concern that hormonal contraceptives may have an adverse effect on the progression of unidentified breast cancer. Evidence is lacking as to whether breast examinations can reduce breast cancer mortality. Age and family history are most likely to single out women who may benefit from a clinical breast examination; however, this group of women is likely to be older and much less likely to be considering hormonal contraception. In younger women, the risk of unintended pregnancy is higher than the risk of breast cancer. Delaying a clinical breast examination until after hormonal contraception is begun is unlikely to have any affect, other than theoretic, on the risk of breast cancer development.

Although there are women who should not be given hormonal contraception and need to be identified, clinical breast and pelvic examinations are not likely to detect disqualifying conditions. The appropriate screening measures for identifying women who should not be given hormonal contraceptives are a thorough history and blood pressure measurement.

There is evidence that women using hormonal contraceptive methods are less likely to use condoms, and they have been shown to be at a higher risk of acquiring STDs. All women using hormonal contraceptives should receive thorough counseling about STD risk, the importance of wise choices, testing for Chlamydia and gonorrhea, Papanicolaou screening, and condom use. Hormonal contraceptives should not be withheld on the detection of gonorrhea or chlamydial infection. The concern that hormonal methods may worsen progression of cervical intraepithelial neoplasia (CIN) or cancer prognosis may be valid, but the authors argue that the risk of pregnancy in young women is of greater concern. Women with CIN or cervical cancer who are awaiting treatment do not need to avoid hormonal contraception, according to these authors.

The authors conclude that breast and pelvic examinations, STD screening, and testing for cervical cancer are all important features of health care but not a necessary part of determining who is a candidate for hormonal contraceptive use. “Because these conditions [breast cancer and cervical cancer] are uncommon … and the countervailing health benefits of effective contraceptive protection so powerful, hormonal methods should not be withheld from a woman who understands the implications of the potential risks involved and nevertheless wishes to defer recommended screening.”

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Copyright © 2002 by the American Academy of Family Physicians.

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