A recent study in JAMA Internal Medicine estimates that of the 2.6 million young women aged 15 to 20 years in the United States who received a bimanual pelvic examination, more than half of these examinations were potentially unnecessary. Similarly, an estimated 1.6 million individuals received potentially unnecessary Pap tests.
“This study suggests that [health care] providers and young women need to communicate clearly and often about the best time for these tests,” Jin Qin, ScD, an epidemiologist at the Centers for Disease Control and Prevention, and his colleagues said. “We want to ensure that guidelines are followed, and lives are saved.”
.jpg)
“Parents of adolescents and young women should be aware that cervical cancer screening is not recommended routinely in this age group of 15 to 20 years old. Pelvic exams are not necessary prior to getting most contraceptives and are often not needed to screen for sexually transmissible infections,” senior author George F. Sawaya, MD, University of California San Francisco, said.
Pelvic examinations have historically been performed annually on asymptomatic women, even though the American College of Obstetricians and Gynecologists recommended in 2018 the examination only be performed when indicated by medical history or symptoms. The bimanual pelvic examination (BPE) is palpation of the internal pelvic organs with the insertion of 2 fingers into the vagina accompanied by simultaneous abdominopelvic pressure. The Papanicolaou (Pap) test is a procedure used for cervical cancer screening by placing a speculum inside the vagina to collect cells from the cervix.
This study used data from the National Survey of Family Growth (NSFG), a multistage, probability-based, nationally representative sample of men and women aged 15 to 44 years in the US. The population of this cross-sectional analysis was adolescent girls and young women aged 15 to 20 years in the years 2011-2017. The survey included two questions about receiving a BPE and Pap test. A potentially unnecessary BPE is defined as those performed as part of a routine examination among female respondents who were not pregnant, did not use an IUD, and did not have STI treatment in the past year.
The final sample size was 3,410 respondents. Among the young women, 4.8% (95% CI, 3.9%- 5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months. Approximately 2% reported using an intrauterine device (IUD). Women who used hormonal contraception methods other than an IUD were 31% more likely to receive a BPE (aPR, 1.31; 95% CI, 1.11-1.54).
Nearly one-fourth (22.9%; 95% CI, 20.7%- 25.3%) of young women aged 15 to 20 years in the United States, or an estimated 2.6 million individuals, received a BPE in the past 12 months. More than half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals.
Approximately 19.2% (95% CI, 17.2%-21.4%), or an estimated 2.2 million young women, received a Pap test in the past 12 months. About three-quarters (71.9%; 95% CI, 66.0%-77.1%) of all Pap tests performed were potentially unnecessary, representing approximately 1.6 million young women in the United States. Almost all potentially unnecessary BPEs were performed at the same visit with a potentially unnecessary Pap test (97.7%; 95% CI, 94.8%-99.0%).
Compared to young women with private health insurance, those with public insurance (aPR, 0.87; 95% CI, 0.78-0.97) or no insurance (aPR, 0.83; 95% CI, 0.72-0.97) were less likely to report receiving a BPE. Race/ethnicity and STI treatment were not found to be associated with receipt of BPE when adjusting for other covariates.
In 2014, the Medicare payment was $37.97 for a screening pelvic examination and $44.78 for a Pap test. As such, assuming the Medicare payments equals the cost, potentially unnecessary BPEs and Pap tests cost more than $123 million in one year.
Qin, Sawaya, and their colleagues believe 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.”
