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When women come to your facility for hormonal contraception, is it mandatory for them to receive a breast and pelvic examination prior to getting a prescription for hormonal birth control? In most cases, waiting to schedule such exams causes an unnecessary and potentially dangerous delay, according to a review of existing recommendations performed by researchers at the University of California, San Francisco (UCSF) Center for Reproductive Health Research and Policy and colleagues.1
Delay can be dangerous for women when it comes to contraception; unintended pregnancy has important health risks and is very common when contraception is not used, states Felicia Stewart, MD, co-director of the UCSF Center for Reproductive Health Research and Policy and lead author of the review.
Approximately 1.5 million unintended pregnancies occur among women who are not using a method of contraception at the time;2 however, most of them have used contraception in the past or plan to do so in the future, notes Stewart. For that reason, reducing obstacles to starting effective methods is a priority, she notes.
"Health policy should be honest and ethical," Stewart says. "It is not honest to imply that breast and pelvic exam are necessary for safe initiation of hormonal methods for most women, and [it is] not ethical to coerce women about routine health screening unrelated to hormone use."
Look at the review
The researchers examined and summarized published literature and recommendations from relevant professional organizations regarding the role of clinical breast and pelvic examinations in the provision of hormonal contraceptives, including pills, implants and injectables available in the United States. Progestin-releasing intrauterine devices were not included because the pelvic exam is part of the insertion process.
Consensus developed during the last decade supports a change in practice that such hormonal contraception can safely be provided based on careful review of medical history and blood pressure measurement. For most women, no further evaluation is necessary, the researchers conclude.
"We agree that hormonal methods are not a wise choice for some women who have serious medical conditions and that routine preventive care services are important," states Stewart. "All women should be advised about recommended screening for STDs, cervical and breast cancer, and these services are an essential part of family planning and reproductive health care."
The researchers note the Geneva-based World Health Organization (WHO) guidelines for identifying conditions that preclude use of hormonal contraception: pregnancy, breast cancer, hypertension, certain heart and liver diseases, and diabetes mellitus. Women with a history of thromboembolic disease, stroke, or migraine headaches with focal neurological symptoms also are advised to avoid these methods, as are women who are fewer than six weeks postpartum and breast-feeding, and those older than age 35 who smoke more than 15 cigarettes per day.
The WHO guidelines suggest cautious use of hormonal contraception in women with hyperlipidemia, women fewer than 21 days postpartum, women breast-feeding from six weeks to six months postpartum, light smokers older than age 35, and women using medications affecting liver enzymes. Additional cautions apply to women receiving estrogen-containing medications but not progestin-only medications; these include agents for biliary tract disease and use by women who are undergoing major surgery with prolonged immobilization.
When do you examine?
If a first-time patient presents with abnormal bleeding, discharge, or pain, a pelvic examination is appropriate, states Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville. In the absence of a specific indication for an examination, however, conducting a "stirrup-free" [no exam] visit can be conducive to building rapport with a new patient that much faster, he states. At a subsequent visit, a physical examination and cytology can be performed.
Programs that provide hormonal contraceptives without requiring a pelvic examination can expand low-income women’s access to such methods and improve the chances that they will obtain other reproductive health services, according to an analysis of one such program.3
First Stop, an 18-month demonstration project that operated in 1996-1997, provided low-income adult women in California with hormonal contraceptives without requiring a pelvic examination. After the initial First Stop visit, 38% of women adopted a more effective method than they had used at last sex, 47% remained with the same method, 12% switched to a less effective method, and 3% accepted no method. Of clients who were referred for additional medical care, 73% followed through on their referrals.
The project showed that many women appreciate being able to obtain hormonal methods of contraception without a mandatory pelvic examination at the same visit, says Cynthia Harper, PhD, a demographer at the UCSF Center for Reproductive Health Policy and Research and lead author of an analysis of the project.
"The services allowed women to switch to more effective contraceptive methods than they had been using before their First Stop visit," says Harper.
Simplified requirements such as those used in the First Stop program mean that health care providers have more flexibility in meeting the needs of their established and new patients to offer services when the woman needs them, observes Stewart.
"We need to treat contraception as an urgent’ health issue just like the many other health problems that warrant an immediate — if brief — health care service to deal specifically with an urgent condition," Stewart advocates.
1. Stewart FH, Harper CC, Ellertson CE, et al. Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs. evidence. JAMA 2001; 285:2,232-2,239.
2. Brown S, Eisenberg L, eds. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: National Academy Press; 1995.
3. Harper C, Balistreri E, Boggess J, et al. Provision of hormonal contraceptives without a mandatory pelvic examination: The First Stop demonstration project. Fam Plann Perspect 2001; 33:13-18.