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.
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 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.
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.
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?