Before Prescribing an Oral Method, Many Clinicians Require a Pelvic Exam
Nearly one-third of physicians and advanced practice nurses specializing in obstetrics and gynecology, family medicine and women’s health require a pelvic examination before prescribing an oral contraceptive, according to a national survey conducted in 2008–2009.1 Nurses in women’s health or obstetrics and gynecology are less likely than obstetrician-gynecologists to require a pelvic exam (odds ratio, 0.6), whereas physicians and nurses in family medicine are more likely to do so (1.5 and 2.4, respectively). Clinicians who work in private practices, live in the South or report that at least half of their patients receive Medicaid also have elevated odds of requiring an exam before dispensing oral contraceptives (1.6–2.3).
The researchers note that according to both the World Health Organization and the American College of Obstetricians and Gynecologists, oral contraceptives can be safely prescribed without a pelvic examination, and they argue that such a requirement may pose a barrier to contraceptive access. A mailed survey collected data from a national probability sample of physicians specializing in obstetrics, gynecology or family medicine and advanced practice nurses specializing in these fields or in family planning or women’s health. Respondents were asked "Do you require a pelvic examination when prescribing oral contraceptives to your patients?" They also answered questions about their practice, training and personal characteristics. Pearson’s chi-square tests were used to assess overall categorical differences, and adjusted Wald tests for mean differences; finally, logistic regression analyses examined associations between clinician and practice characteristics and requiring a pelvic examination.
In all, 1,196 clinicians completed the survey. Fewer than half of obstetrician-gynecologists and family medicine physicians were female (41–45%), and most worked in private settings (78–81%). By contrast, nearly all advanced practice nurses were female (94–99%), and while 42–57% worked in private practices, 23–36% worked in community or family planning clinics. The patient populations seen by these different groups varied accordingly: Physicians were less likely than nurses to see teenage, minority, uninsured or Medicaid-insured patients; advanced nurses in women’s health or obstetrics and gynecology were the most likely of all groups to see such patients.
One-third of the clinicians surveyed always required a pelvic examination before prescribing an oral contraceptive, and more than four in 10 usually required one. Similar proportions of obstetrician-gynecologists and family medicine physicians said they always required a pelvic exam (29% and 33%, respectively). Nurses in women’s health or obstetrics and gynecology were the least likely to require an exam (17%), and nurses specializing in family medicine were the most likely to do so (45%).
In regression analyses, nurses in obstetrics and gynecology or women’s health were less likely than obstetrician-gynecologists to require a pelvic exam (odds ratio, 0.6), whereas physicians and nurses in family medicine were more likely to do so (1.5 and 2.4, respectively). With each additional year of their age, clinicians were more likely to require an exam (1.03), and those who worked in private practice were more likely than those who worked in a community or family planning clinic to do so (2.3). Clinicians who lived in the South were more likely than those in the West to require an examination (1.7), and those who reported that at least half of their patients were insured by Medicaid were more likely to require an exam than were those who reported a smaller proportion of Medicaid patients (1.6).
Given the hypothetical case of a 16-year-old patient who was never-married, was nulliparous and reported inconsistent condom use with an older partner, clinicians who required a pelvic exam before prescribing an oral contraceptive were more likely than others to recommend a Pap test (91% vs. 74%) and a human papillomavirus (HPV) test (58% vs. 48%). For a hypothetical 24-year-old who was unmarried, was nulliparous, had a new sexual partner and was making a family planning visit, clinicians who required a pelvic exam were more likely than others to recommend an HPV test (60% vs. 49%) and less likely to recommend a chlamydia test (85% vs. 91%). All of these recommendations are contrary to current screening guidelines.
The researchers call for more effective dissemination of guidelines for STD and cancer screening, as well as for contraceptive counseling, and suggest that such information may be especially helpful to older clinicians in private practice. Given the current biennial screening protocol for cervical cancer and the availability of urine-based STD testing, the researchers state that "women seeking oral contraceptives do not need cancer or [STD] screening to safely use the medication," and they believe that "a timely appointment and the opportunity to focus a visit on selecting an effective and suitable method is important."—J. Thomas