Reviewed by Hansa D. Bhargava, MD
From the WebMD Archives

Jan. 7, 2020 -- Every year, millions of adolescents and young women are having Pap smears and pelvic examinations they may not need, according to a new study.

National guidelines recommend these invasive exams not be routinely done until a young woman turns 21. But a new study in JAMA Internal Medicine found that more than 2 million girls and young women below that cutoff receive a Pap test each year -- and nearly three-quarters of them may not be needed.

The study examined data from the National Survey of Family Growth that focused on responses to questions about gynecological care from more than 3,400 young women aged 15 to 20 gathered from 2011 to 2017. They were asked if in the last 12 months they’d received a bimanual pelvic exam -- an exam in which a doctor or nurse puts one hand inside the vagina and the other on the abdomen -- or a Pap smear, which is a cancer screening test in which an instrument is inserted into the vagina to take sample cells for testing.

When participants said they had been given either or both exams, the survey requested the reason they’d been told for them. “We were able to define a group who weren’t having symptoms as far as we could tell. They weren’t being considered for an IUD, weren’t being treated for a sexually transmitted infection,” says George Sawaya, MD, senior author of the study and a professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “We wanted to find the proportion that seemed to be asymptomatic but getting these exams anyway.”

Using that data, Sawaya and his co-authors estimate that nearly one-quarter of young women aged 15-20 have received a pelvic exam in the last year. That’s 2.6 million girls. More than half of the exams -- 1.4 million -- may not have been needed. While the number who received a Pap smear was smaller, at 2.2 million, the fraction of instances that may not have been necessary was higher.

“Any time we’re doing anything in the name of prevention -- and doing a pelvic examination in an asymptomatic person is by definition prevention -- there are unintended consequences,” says Sawaya. “There’s the possibility of a false positive, which leads to more interventions and other studies that may be unnecessary.”

These tests may also cause anxiety and depression, Melissa A. Simon, MD, writes in an editorial accompanying the study. Simon works in the Department of Obstetrics and Gynecology and Center for Health Equity Transformation at Northwestern University’s Feinberg School of Medicine.

“Many women (younger and older) associate the bimanual pelvic and speculum examinations with fear, anxiety, embarrassment, discomfort, and pain,” she says in the editorial. “Girls and women with a history of sexual violence may be more vulnerable to these harms. In addition, adolescent girls may delay starting contraception use or obtaining screening for sexually transmitted infections because of fear of pelvic examination, which thus creates unnecessary barriers to obtaining important screening and family-planning methods.”

And all those unnecessary tests cost money -- the study estimates as much as $123 million each year, just for the pelvic exams and Pap tests.

“This is really a well-written and important study,” says Paula Hillard, MD, a professor of obstetrics and gynecology at Stanford University School of Medicine. “We’ve done a good job of teaching gynecologists to do pelvic exams, but only recently people like me who do adolescent gynecology and adolescent medicine are getting across important messages about providing good gynecological care for adolescents.”

Jessica Kahn, MD, director of the Division of Adolescent and Transition Medicine at Cincinnati Children’s Hospital, agrees. “The results have significant implications for clinical practice: Education is clearly needed for clinicians to improve awareness of evidence-based guidelines and to ensure that bimanual examinations and Pap tests are performed only when medically indicated,” she said in a statement.

Show Sources

JAMA Internal Medicine: “Prevalence of Potentially Unnecessary Bimanual Pelvic Examinations and Papanicolaou Tests Among Adolescent Girls and Young Women Aged 15-20 Years in the United States.”

CDC: “Cervical Cancer Screening Guidelines for Average-Risk Women.”

George Sawaya, MD, professor of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco.

Paula Hillard, MD, professor of obstetrics and gynecology, Stanford University School of Medicine.

Jessica Kahn, MD, director, Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital.

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