Women who seek most forms of contraception do not need a routine pelvic examination before they are prescribed a contraceptive. Still, these exams are routine for many OB/GYN offices and reproductive health clinics, and this creates a barrier for some women — particularly those who have experienced sexual assault and intimate partner violence, according to new research.1

“I think what prompted this study is that contraception has been recommended since 1994 to be safely prescribed without pelvic examination,” says Hunter Holt, MD, co-author of the study and a clinical fellow in the department of family and community medicine at the University of California, San Francisco. Holt notes that, except for IUDs, contraceptives can be provided without a pelvic exam.

For example, the American College of Obstetricians and Gynecologists (ACOG) recommends that pelvic examinations be performed when indicated by medical history or symptoms. ACOG also recommends that the decision to perform a pelvic exam should be a shared decision between the patient and her physician.2

Recent evidence shows that a large number of providers still require pelvic exams before prescribing contraceptives, Holt says. This poses a problem to women who have experienced sexual violence. This is a vulnerable population that includes about one in five or six women in the United States.3 Women who have experienced sexual violence or were pressured by an intimate partner into having sexual intercourse may be reluctant to visit a reproductive health provider because of their fear of the pelvic exam, Holt explains.

“It can cause retraumatization for these people,” he adds.

Holt’s research revealed that 32.4% of 1,490 women participants reported experiencing pressured sex. Also, 19.4% of the women said they had experienced verbal abuse, and 10.2% said they had been physically abused. Women who experienced pressured sex often were significantly more likely to delay a clinic visit for birth control. Also, 13.2% of participants reported delaying obtaining contraception to avoid a pelvic examination.1

“We didn’t find any association with physical abuse or verbal abuse in reluctance to go to the clinic,” Holt says.

The best method for family planning providers is to not require a pelvic exam for contraception. “For cancer screening, or if someone is having symptoms, they need a pelvic exam,” he says. “I think that should be communicated to the patients.”

For instance, clinicians can tell patients over the phone, “We do not require a pelvic exam for contraception,” he says. It might complicate things for clinics, but it is a conversation that can be held in a trauma-informed manner.

Several decades ago, pelvic exams were widely used for screening for sexually transmitted infections (STIs). But the exams are no longer as necessary for STI screening. “With the availability of urine and gonorrhea-chlamydia testing, there is less need for a pelvic exam for STIs,” Holt explains. “If physicians are suspicious of pelvic inflammatory disease, then they might perform the pelvic exam.”

In this case, the patient might report discharge or pain in the abdomen or in the vaginal area. Since the person is symptomatic, the provider can initiate a discussion about the pelvic exam, he adds.

“It’s really important to just have open communication with patients,” Holt says. “Acknowledge their history and experiences and how these affect them, and talk through what’s required and every aspect of the exam.”

If a patient with a history of intimate partner violence or sexual trauma needs a Pap smear, then the provider can talk it through and go very slowly, using neutral terminology, Holt suggests. For example, instead of asking patients to lie down on the bed, ask them to lie on the table. Also, do not use the word “stirrup.” Instead, call it a foot rest, he adds.

“Giving patients dignity and autonomy is super important, and that’s how I approach every patient,” Holt says. “Show them dignity and respect, and try to make it as painless as possible.”

Given the study’s findings that the pelvic exam can be a significant barrier to a vulnerable population of women seeking contraceptive services, family planning clinics and providers should offer these services without the pelvic examination, he says.

REFERENCES

  1. Holt HK, Sawaya GF, El Ayadi AM, et al. Delayed visits for contraception due to concerns regarding pelvic examination among women with history of intimate partner violence. J Gen Intern Med 2020; doi: 10.1007/s11606-020-06334-8. [Online ahead of print].
  2. The American College of Obstetricians and Gynecologists. The utility of and indications for routine pelvic examination. October 2018. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/the-utility-of-and-indications-for-routine-pelvic-examination
  3. National Sexual Violence Resource Center. Statistics. https://www.nsvrc.org/statistics