Unintended pregnancy is a widely recognized public health concern, yet many physicians hold effective contraception hostage, thinking that they are benefiting women by giving them an incentive to obtain important but unrelated health screening.
When the combined oral contraceptive pill was introduced in 1960, the long-term health risks were not known. Initially, a comprehensive health evaluation and follow-up were routine. Since the mid-1990s, however, many international and U.S. professional organizations (e.g., the World Health Organization, the Royal College of Obstetricians and Gynaecologists, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, International Planned Parenthood Federation, the U.S. Agency for International Development) have released revised statements affirming that a pelvic examination and laboratory tests are not necessary before initiation of hormonal contraception. Many also indicate that a physical examination is unnecessary.1 In this issue of American Family Physician, Lesnewski and Prine2 note that although evaluations of weight and blood pressure influence the appropriate contraceptive choice, the rest of the physical examination contributes little to this assessment.
Evaluations often performed as part of well-woman visits are not required for the purposes of safely prescribing hormonal contraception. Periodic Papanicolaou tests are important preventive measures but are unrelated to the use of hormonal contraception. Screening for sexually transmitted diseases also is important, but performing these tests or waiting for results should not delay a prescription for hormonal birth control. With the advent of sensitive nucleic acid amplification tests for chlamydia and gonorrhea, this screening may even be performed using a urine sample, obviating the need for a pelvic examination as part of the contraceptive visit. Although clinical evidence that breast examinations reduce mortality from breast cancer is lacking, breast examinations generally are recommended for women after a certain age, ranging from 20 to 50 years. Breast cancer is rare in women younger than 30 years, and women older than 40 constitute a small number of those seeking hormonal contraception. Thus, situations in which a breast examination is a necessary part of the contraceptive visit are uncommon.
Clinical encounters for contraception present opportunities to provide or encourage other important preventive health measures, but these visits and interventions also create impediments to the use of effective contraception and therefore may cause harm. Undesired pregnancies often occur while women hesitate to obtain a clinical visit because of fear of an uncomfortable examination.1 A study3 from 2005 noted that during visits for initiating oral contraception, physicians asked few questions and provided little information regarding screening for contraindications, pill-taking instructions, side effects, and warning signs. Some physicians then blocked the use of oral contraception for reasons not considered to be contraindications.
A U.S. study4 of urban adolescents found that those who were permitted to delay the pelvic examination when initiating oral contraception had higher rates of condom use, fewer pregnancies, and similar rates of sexually transmitted diseases compared with those who had a pelvic examination when contraception was initiated. A California study5 found that, of adult women who were able to obtain birth control without a pelvic examination, 76 percent stated that it was important for them that a pelvic examination was not required, 73 percent subsequently followed up on referrals for additional medical care, and 38 percent changed to a more effective contraceptive method. Women in these and other studies were screened initially by medical history and blood pressure measurement, and some also had a breast examination.
By providing hormonal contraception uncoupled with other evaluations, physicians could improve access to contraception, avoid reinforcing fears about the safety of hormonal contraception (and therefore possibly further improve compliance), and allow women to weigh for themselves the risks of delayed screening against the risks of delayed access to contraception. Medical history and blood pressure measurement are the most useful screening approaches to detect contraindications to hormonal contraception use, and they may be performed without a clinic or a physician.