Annual Visits to the Gynecologists Have Just Become More Affordable For Many. But Are They Still Necessary?


When I was a peer sexuality education at the UMASS-Amherst, one of my tasks was to conduct the mandatory pre-appointment workshops that students needed before seeing a gynecologist or nurse practitioner for prescription birth control. The idea behind the workshops was to make sure all young women arrived at their appointments having already learned about their contraceptive options so that they had a good idea of what might work for them, thus shortening their meeting with the health care provider (we only had a handful at the health center). One of the other things we did was walk them through a standard gynecological exam since many of them had never had one and some got understandably nervous at the thought of the stirrups and the speculum. My favorite part was always the movie—shown on a reel-to-reel projector mind you—that we liked to call Marcia Brady Gets a Pelvic. Even though it was the early nineties, the movie, which starred a young woman with long straight blond hair (parted neatly in the middle) and bell-bottoms, was clearly made in the seventies. We watched and giggled a little as “Marcia” met with her gynecologist and received a standard annual exam complete with an examination of her external genitals, an internal exam with speculum, a pap smear, and a breast exam.    

Last week, preventive care coverage for women under the Affordable Care Act kicked in requiring most insurers to fully cover annual checkups for women, including yearly visits with a gynecologist like the one “Marcia” had. Obviously, this is great news, but it comes just months after the American College of Obstetricians and Gynecologists (ACOG) teamed with the American Cancer Association and the U.S. Preventive Services Task Force to issue new guidelines which pushed back the age at which young women should begin to have internal pelvic exams and suggested that most women only need pap smears once every three years. Given these guidelines, some health care professionals and women are questioning whether an annual visit to the gynecologist is still necessary. 

ACOG says yes. Its Committee on Gynecological Practice released an opinion this month underscoring the College’s support for the well-woman’s visit: 

“The annual health assessment (“annual examination”) is a fundamental part of medical care and is valuable in promoting prevention practices, recognizing risk factors for disease, identifying medical problems, and establishing the clinician–patient relationship.”

Currently, the College recommends that young women see a gynecologist beginning between ages 13 and 15. The main focus of this visit should be on patient education and the visit does not usually include an internal pelvic exam though it should include an external examination of the patient’s genitals. I was pleased to see that ACOGs suggests the visit should also include “age-appropriate discussion of anatomical development, body image, self-confidence, weight management, immunizations (including the human papillomavirus vaccine), contraception, and prevention of STIs.”  These are the kinds of conversations that too many young women (women of all ages actually) are not having with their health care provider or anyone else for that matter. Moreover, these conversations can certainly help establish a relationship with a provider that with luck can last over many years. 

After that first visit, the committee continues to recommend annual appointments to assess a patient’s general health as well as her sexual and reproductive health. The components of the annual visit, however, change depending on a woman’s age, prior health, and risk of STIs.  Here’s a summary of what ACOG and other groups recommend.

Pelvic Exam

Though a standard pelvic exam actually has three parts (an external examination of the genitals, a speculum exam of the cervix and vagina, and a manual internal examination of the uterus), the phrase tends to conjure up those images of the stirrups and the speculum and is often used to denote just the internal exam. Currently, ACOG does not recommend internal pelvic exams for women younger than 21 regardless of whether they are sexually active and suggests that women can received prescriptions for hormonal contraception without an internal exam.

ACOG continues to recommend that women over 21 get a pelvic exam every year though the committee did acknowledge that this guideline is based on logic and not evidence as there is “no data to support a specific time frame or frequency of such examinations.” In fact, the committee says that the decision on whether to do the internal exam is one that should be left to the patient and her provider. 

It points out, however, that a pelvic exam is always appropriate regardless of a woman’s age if she is reporting menstrual disorders, vaginal discharge, infertility, vaginal discomfort, pelvic pain, abnormal uterine bleeding, or changes in bowel or bladder function.

Pap Smears

Pap smears screen for cervical cancer. Health care providers typically perform this test during the speculum part of the pelvic exam by scraping some cells off the surface of the cervix (using something that looks like an extra-large mascara brush to me). Pap smears can not only detect cervical cancer, they can pick up pre-cancerous changes to the cervix which can then be treated to prevent cancer from ever developing. Pap smears were introduced in the forties and this routine screening has reduced the rates of cervical cancer in this country by an impressive 75 percent. 

While it was once recommended that women start getting these tests as soon as they became sexually active and then get one every year after that, recent guidelines suggest that especially when paired with tests for HPV (which is the cause of most cases of cervical cancer) they can be effective even when given much less frequently. 

ACOG now suggests that women under 21 do not need pap smears but this test should be given when a woman turns 21 regardless of whether she is sexually active. From 20 to 29, women should be tested every three years. Women between 30 and 65 have a choice of getting a pap smear every three years or combining a pap smear with an HPV test and getting both tests every five years. Women who are over 65 or have had a hysterectomy in which the cervix was removed do not need pap tests unless they have a history of pre-cancerous lesions or are otherwise at high risk. 

It is important to note, that the HPV vaccine does not affect these recommendations.  Women who have been vaccinated should follow the same pap-smear schedule.  

STI Screenings

One of the points we used to stress after we would watch “Marcia’s” pelvic exam is that STI testing is not a standard part of the annual gynecological exam meaning that women who had had an exam should not assume they’d been tested and women who wanted to be tested needed to ask for it. This holds true today and there are some guidelines on who should requests such tests. 

Obviously, anyone who is sexually active and has symptoms such as discharge, itching, or burning should be screened for possible STI infections but since STIs are so often asymptomatic women who feel fine should consider screening as well.  The Centers for Disease Control and Prevention (CDC) specifically recommends that all sexually-active women under 25 be tested for Chlamydia each year. ACOG’s new committee opinion agrees and points out that an internal pelvic exam is not necessary as providers can screen for both Chlamydia and gonorrhea using urine tests. As for older women, the CDC recommends screening those at increased risk which include women who have multiple sex partners, who do not use condoms consistently, who are having sex under the influence of alcohol or drugs, or those who are having sex in exchange for money or drugs.

Breast Exams

During a breast exam a heath care provider gently palpates a patient’s breasts to feel for lumps that could be tumors (though it is comforting to know that most—8 out of 10—lumps found are not actually cancerous). According to ACOG there is no data on the ideal age to start clinical breast exams in low-risk patients but based on current information and expert opinion, the College (along with the American Cancer Association and the National Comprehensive Cancer Care Network) recommend that women ages 20 to 39 receive a breast examination every one to three years and that women 40 and over receive one annually.

ACOG also points out that the annual well-woman exam is a good place for women to learn about the importance of breast self-awareness and self-exams. Women who know what their own breasts feel like are in a better position to recognize changes and should immediately report such changes to her health care provider.  (Click here for a step-by-step guide to doing a self-breast exam.)

In the past the annual trip to the gynecologist was pretty much synonymous with a pelvic or a pap smear. In fact, that’s why you made the appointment—to get your pelvic, your pap, and possibly your prescription for birth control. Now, just as these annual appointments are likely to be covered by your insurer, public health experts have decided that most of us don’t need a pap or even a pelvic every year and, in fact, that we can get the coveted pill prescription without having either of these tests. So it’s understandable to wonder whether it’s still worth taking the time out of our busy schedules to see our gynecologist each and every year (I don’t know about yours, but mine always keeps me waiting forever). 

In the end, experts say it’s up to us but they seem to agree that it is a good tradition to keep in order to check our overall health and help maintain an ongoing relationship with our health care providers. 

My appointment is on September 26th, and yours?

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  • cmarie

    The Marcia Brady thing isn’t funny… it’s sad.  Maureen McCormack has said she had a cocaine addiction for five years, had sex for durgs,  two abortions, bulimia, and suffered depression her whole life. 

  • jennifer-starr

    Granted, I’m only on my first cup of coffee, but I do know that Marcia Brady is a fictional character, and  I’m wondering how in the world you interpreted any of the above as an attack on actress Maureen McCormack. 

  • cmarie

    Maureen McCormack played Marcia Brady… apparently so well that Amherst’s  “movie”  went out of it’s way to dress the actress as a believeable 70’s style Marcia… oh and they also used the fictional name…

    a casual attitude towards reproductive health … great fun when it’s just a job… not so much when it’s someone’s reality…..

  • jennifer-starr

    I was born in the early 70s so yes, I am aware of who played Marcia Brady. But if you read the statement above clearly, you’ll see that that was not the official name of the movie–the students liked to call it that because the movie was made in the ’70s and the actress in the movie resembled Marcia–as referenced above : 

    My favorite part was always the movie—shown on a reel-to-reel projector mind you—that we liked to call Marcia Brady Gets a Pelvic. Even though it was the early nineties, the movie, which starred a young woman with long straight blond hair (parted neatly in the middle) and bell-bottoms, was clearly made in the seventies.

    I will point out again that none of this has a thing to do with the personal tragedies of Maureen McCormack, or with the actual Brady Bunch show (which was inferior to the Partridge Family–yeah, I said it) or with the subject of the article.You simply misunderstood and jumped to conclusions. 

  • martha-kempner

    Hey,

     

    I just wanted to say that Jennifer is correct, the movie had nothing to do with Marcia Brady or Maureen McCormack.  We were just making a comment/joke about how obviously dated the movie was. 

     

    Martha

  • arachne646

    The AMA guidelines are to have HIV testing once yearly, if you’re sexually active, and more often if needed. You don’t need to see a doctor, for screening and a quick test, you just need a mouth swab. A blood test is needed to confirm or correct quick test positives.

  • eliz52

    I’d urge US women to take a close look at the clinical evidence for the need for the well-woman exam. I’m Australian and would never agree to one, but they’re not recommended here or in the UK or many other countries. One in three US women will have a hysterectomy by age 60, one of the highest rates in the world, most unnecessary…so much for the well-woman exam!
    The facts are: routine breast exams…no evidence they help, but they lead to biopsies…they have not been recommended for many years.
    Routine pelvic exam is of poor clinical value and carries risk, even unnecessary surgery. It does not detect early ovarian cancer…your ovarian cancer rates are the same as countries that don’t do routine pelvic exams. Your Dr Carolyn Westhoff partly blames this exam for your high hysterectomy rate and the loss of healthy ovaries.
    Pap testing – Finland has the lowest rates of cc in the world and sends the fewest women for biopsies/over-treatment…since the 1960’s they’ve offered a 6-7 pap test program, 5 yearly from age 30 to 60. The Dutch have the same program but will move with the evidence and will shortly introduce a new program, 5 hrHPV primary triage tests offered at ages 30,35,40,50 and 60 (and there is also a self test HPV option, the Delphi Screener) only the roughly 5% who test HPV positive will be offered a 5 yearly pap test. The vast majority will be HPV negative, not at risk and will be offered the HPV primary testing program. Those HPV negative, confidently monogamous or no longer sexually active can forget all further testing. This program will save more lives and spare huge numbers of not-at-risk women from unnecessary pap testing and potentially harmful over-treatment. (damage to the cervix can lead to cervical stenosis, infertility, c-sections, cervical incompetence, premature babies, miscarriages, etc)
    Women under 30…not one country in the world has shown a benefit pap testing them, but young women produce the most false positives. HPV primary testing is not recommended either as 40% would test positive, most have transient and harmless infections that will clear within a year or two…by age 30 only 5% are HPV positive.
    IMO the pap test has been horribly and recklessly overused to create a highly lucrative industry in the over-treatment of CIN….there was never a need to worry and harm so many, now there is no excuse.
    As a low risk woman my risk of cc is near zero, I have always declined pap testing, the risks were too high for me. The lifetime risk of cc is 0.65% while the referral rate for colposcopy/biopsy is a shocking 77% thanks to serious over-screening…it would be even higher in the States with some women still being tested annually.
    Being informed enables women to protect their healthy bodies from harmful excess. Hopefully, more women will walk away from this harmful and useless annual ritual…that does nothing more than provide profits for the medical profession. Mammograms – beware, the Nordic Cochrane Institute found they are of little benefit but lead to significant over-diagnosis, they do not recommend them. There are powerful vested interests in cancer screening so look carefully at all medical advice, is it in YOUR best interests?

  • gyno123

    It is highly recommended that all women undergo routine gynecological exams, which play a pivotal role in the prevention and early detection of diseases. These exams are not fun, but are a crucial part of every women’s life and should begin when the patient becomes sexually active, or by age 21 years. Exams should be performed annually.

  • eliz52

    Gyno 123, Interesting the clinical evidence does not support your assertion – instead of providing women with directives, perhaps, some evidence to back up your claims may be more respectful and persuasive. There are numerous articles pointing out the risks with routine pelvic exams and their poor clinical value – routine breast exams – where is the evidence of benefit? We know they lead to excess biopsies…so does self-examination, which hasn’t been recommended for many years.

    That leaves pap testing – terribly overused – far too often and too early and now we can identify the roughly 5% of women aged 30 or over who have some chance of benefiting from a 5 yearly pap test, sparing the vast majority of women from unnecessary testing, false positives and potentially harmful over-treatment. Women not yet sexually active of any age simply accept risk for no benefit with cervical screening – countries that practice evidence based screening/medicine do not test any women before age 30 – it doesn’t help, but leads to worry and harm.

    I’d urge all women to be careful of anyone simply ordering or scaring you into routine exams and cancer screening – evidence based medicine is the best medicine.

    HPV Today, Edition 24 sets out the new Dutch program – registration is free.

    Dr Carolyn Westhoff, “Is the routine pelvic exam obselete?” – online & numerous other articles.

    This exam has not been recommended for many years in the UK, Australia, NZ and elsewhere.

    The Delphi Screener – see the Delphi Bioscience site

    The Nordic Cochrane Institute are an “independent” medical research group – their website contains a study on routine breast exams and their excellent paper, “The risks and benefits of mammograms” – essential reading for any woman considering breast screening. The real thing, real information, not spin, hype, misinformation etc…

    There are doctors prepared to work with you and not simply give orders or use coercion to force unnecessary exams and elective cancer screening – go doctor shopping and find someone who’ll act in your best interests and foster a respectful relationship.

  • mary-payne

    Gyno123 can you provide a better site than the one you link that convinces me that routine gynecological exams are of any value? It seems that site is written for lower high school students. I would preferably like a peer reviewed journal that outlines the risks and benfits of annual routine gyn exams. And I would like you to answer me the question that if you they are so “crucial”, can you explain why they are not part of women’s routine health care in most European countries,Australia and New Zealand? Is the morbidity and mortality higher in those countries? It seems that the morbidity is actually higher in the US with the astronomically high hysterectomy rates.

    Do you think you could move into the 21st century and treat women as though they are autonomous adults who are capable of being given information (ie risks and benfits) and left to make up their own mind whether they wish to partake in “preventative” health? You know like men are?

  • pygmygirl

    gyno123, who the hell are you to paternalistically order women into having a pelvic and pap?  Sorry sweetie, but the days of paternalistic ordering of women to just do what they’re told for their own good are all but over.  Please back up your paternalistic, archaic bullshit with some actual facts.  Maybe you need to brush up on the latest medical journals, or the WHO recommendations.  Sorry, but I didn’t see in your comments ALL of the risk factors explained regarding false negatives, false positives, the unnaceptably high rate of referral for biopsy, LEEP etc for abnormal cells that will fix themselves on their own without any interference.  Oh, what about the damage that can be caused by these follow on procedures?  What about a watch and wait approach?  Medical personel like you make me sick.  If you are so willing to accept these sorts of risks on women’s behalf without even telling them what the risks are, are you willing to fix and pay for the damage to our cervix’s that can occur later?

    I suppose you even try to tell women that they can’t have birth control without having a pap or pelvic exam.  Never mind that all that is needed for birth control is a blood pressure check and a satisfactory medical history, and that it is ILLEGAL to with hold ANY sort of medication from a woman who asserts her legal right to decline a pap smear or pelvic exam.  I sincerely hope that if you are this sort of monster who operates illegally that you are reported for it. 

  • cp76

    The article raises some good points, but inaccurately states ACOG’s current guidance.

    Obviously, this is great news, but it comes just months after the American College of Obstetricians and Gynecologists (ACOG) teamed with the American Cancer Association and the U.S. Preventive Services Task Force to issue new guidelines which pushed back the age at which young women should begin to have internal pelvic exams and suggested that most women only need pap smears once every three years.

     

    The guidelines the article cites are actually two separate recommendations (neither of which is from ACOG). In March, the US Preventive Services Task Force released new guidance on cervical cancer screening; that same month the American Cancer Society, the American Society for Colposcopy and Cervical Pathology and American Society for Clinical Pathology released joint guidance on the same topic.

     

    Starting Pap tests at age 21 (regardless of sexual activity) is not the big change; it’s been guidance for awhile. In fact ACOG’s current guidance was released in 2009 and recommends not testing before age 21 years, and then every 2 years for women in their 20s and every 3 years for women age 30 and older (Cervical Cytology Screening. ACOG Practice Bulletin No. 109. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 114:1409–20.)

     

    The big change from the March 2012 releases (neither of which are from ACOG) is that these organizations now recommend co-testing (Pap smear and HPV test) every FIVE years for women 30 years and older. So five years in between Pap test.