By Suzanne Batchelor
Thursday, January 15, 2004
Female teens seeking birth control are less likely to undergo pelvic exams. Doctors say that young women's dread of the invasive procedure prevents them from seeking not only contraceptive counseling, but gynecological care in general.
(WOMENSENEWS)--Female teens avoid seeking gynecological care or contraception because they fear undergoing a pelvic exam, many physicians say. They want that obstacle to contraception and health care to be removed for sexually active adolescents.
"The fact is, there isn't anything I would learn from doing a pelvic exam on a young woman that would prohibit me from offering her birthcontrol pills," says Dr. Paul D. Blumenthal,director of contraceptive research and programsat Baltimore's Johns Hopkins University.
The only time to require a pelvic exam for hormonal contraception, he says, is when teens show evidence of infection or have a chronic illness such as diabetes.
"The pelvic exam is specifically for preventive care, for cervical-cancer screening," says Dr. Vanessa Cullins, vice president for medical affairs at New York-based Planned Parenthood Federation of America. "The manual part of the exam, the hand part, is done to assess the size of uterus and ovaries. In a healthy young woman, one with no symptoms, there is no need to perform a pelvic exam prior to beginning contraception, whether the injectables or pills." Injectable contraceptives include DepoProvera and Lunelle.
Blumenthal notes that young women seek clinical attention for two different reasons. "One is contraception and the other is screening for infection. A 16-year-old coming in for contraception has very little chance for cervical cancer, the chances of her needing a Pap smear are almost zero. In many countries of Europe, the national screening (for cervical cancer) doesn't even begin until age 25."
"Teenagers talk about that exam," adds Johns Hopkins' Blumenthal, an obstetrician-gynecologist and public health researcher. "We hear this all the time among teen girls (who say), 'They're going to take that big metal thing and push it into the vagina and it's going to hurt and pinch and it's cold. You'll have to be in a strange, weird position and the doctor will put his fingers in your vagina."
While teen abstinence is desirable, says Blumenthal, those who are going to be sexually active need to prevent unintended pregnancies.
Planned Parenthood's Cullins agrees. "We know sometimes it takes 9 to 12 months before sexually active adolescents will enter health care," she says. "Often they are pregnant when they come to the clinic. The whole object is to prevent unintended pregnancy from the onset of becoming sexually active."
In 1998, Planned Parenthood began a program called HOPE--Hormonal contraception with Optional Pelvic Exam. Since then, HOPE has grown slowly but steadily, says Cullins, an obstetrician-gynecologist. It is now offered at clinics run by almost half of the organization's 126 local U.S. affiliates and she and others would like to see it expand further. "We've noticed that there has been an increase in the number of young women coming to the affiliates because the affiliates offer HOPE," says Cullins.
Although HOPE isn't offered beyond the United States, Cullins says similar programs do provide contraceptives to women in developing countries, following a medical screening but no pelvic exam.
In a statement to Women's eNews about teens and contraception, the American College of Obstetricians and Gynecologists endorsed HOPE's approach, saying "the initial visit for oral contraceptives does not have to include a pelvic examination if the patient requests that it be deferred." It added that "adolescents need special attention at every visit for contraceptive services, including comprehensive counseling about sexuality, sexually transmitted disease and emergency contraception."
Cullins says that the HOPE approach is safe, well endorsed and improves teens' access to contraception. Nonetheless, some physicians resist dropping the pelvic exam from their clinical procedure for prescribing birth-control medication.
A young woman seeking hormonal contraception from her family doctor, for instance, may find still find that a pelvic exam is part of the routine. "A lot of the controversy comes from older physicians who were trained many years ago and are used to a more authoritative, paternalistic practice," Cullins says.
She adds that HOPE and all Planned Parenthood programs operate in accordance with the guidelines and recommendations of the American College of Obstetricians and Gynecologists, the U.S. physicians' professional organization.
Research behind HOPE's clinical approach to teen contraception began to appear in public-health and family-planning journals as early as 1993. The studies, conducted by researchers at Johns Hopkins and elsewhere, showed that the pelvic exam wasn't always medically necessary for young women and that their fear of it was keeping them from seeking contraception.
Cullins says that beyond its basis in published research, HOPE is also a result of doctors' experiences caring for teens who said they disliked and feared the pelvic exam, which can be physically uncomfortable particularly for virginal women, who may still have intact hymens. Caregivers, she says, were also learning that young women were avoiding gynecologic care entirely because of their fear of the exam.
After reviewing a patient's medical history and checking her blood pressure, doctors in HOPE are allowed to defer a pelvic exam for healthy young women requesting contraception.
Similarly, current federal funding regulations for family planning offered to low-income women allow the pelvic exam to be deferred based on the physician's judgment.
Blumenthal says it is important for physicians to remind teens that oral contraceptives do not prevent sexually transmitted infections and that a barrier method--such as a condom--is advisable for preventing infection.
Cullins agrees that in their counseling of young women, doctors should emphasize that hormonal contraceptives don't prevent sexually transmitted diseases. One in four sexually active teens has a sexually transmitted infection, she says. While Planned Parenthood recommends teen abstinence it also counsels sexually active teens on preventing pregnancy and sexually-transmitted disease. The HOPE program encourages young women to avail themselves of the program's preventive care and screening services.
"Cervical cancer is associated with human papilloma virus, HPV, which is sexually transmitted," she says. Screening for cervical cancer with the Pap smear, she says, does not need to begin until some time after a woman becomes sexually active.
Researchers say nearly all women with cervical cancer have the HPV virus, which is now believed to be the main cause of that disease. However, only a small percentage of all women with HPV will develop cervical cancer.
Planned Parenthood's physicians do not recommend intrauterine devices for teens because a young woman's uterus is often too small to hold an IUD and because sexually transmitted infections in women with IUDs can lead to pelvic inflammatory disease and inability to bear children.
Suzanne Batchelor has written on health and medicine for Medscape, CBS Healthwatch and the Texas Medical Association's "Healthline Texas," and for the national science series "Earth and Sky."
Planned Parenthood Federation of America:
Physicians for Reproductive Choice and Health: