How common is it for physicians to refuse to prescribe birth control without a pelvic exam?

In My Humble Opinion
21

My wife is an Ob/Gyn, subspecializing in reproductive endocrinology (i.e., an infertility doc). I asked her about pelvic exams as a prerequisite for birth control pills.

She said there really wasn’t any medical reason to require a pelvic exam before prescribing the Pill, and she did not require it of her patients. Now, this was an offhand response to a question I asked when we were both in the middle of something else, so I’m sure she spared me a lot of nuance and edge cases. But, in general at least, a pelvic exam is not medically required before getting birth control pills. (I assume the answer is different for IUDs. I would imagine you’d need a pelvic exam before implanting a foreign object in your uterus. But I didn’t ask that.)

My wife said that some doctors require a pelvic exam anyway. Some do it, as someone suggested upthread, to pressure patients into getting their yearly pelvic exam. While my wife agrees that yearly PEs are great and all, she doesn’t want to erect unnecessary barriers to women who want birth control. My wife stated it as, the cost to the patient and society of unwanted pregnancy is so high that it outweighs the benefit of the PE, so using birth control as leverage to get the patient to have the PE seems wrongheaded to her.

She also said that some doctors require a PE so they can get more revenue for the visit. The patient is in the office anyway, might as well as ring up the PE. Yay for profit-driven healthcare. My wife is an old fashioned sort who thinks you should do what’s best for the patient even if you lose a few bucks. Luckily she works at an academic medical center, which is only mostly, but not entirely, driven by the profit motive.

22

Gonorrhea and chlamydia infection in women can be detected from a urine specimen but a cervical or vaginal swab has better sensitivity. And any pelvic exam has a component of disease screening in that it will reveal any lesions, discharge or cervical motion tenderness. Anyone who has specific disease concerns or has a high risk lifestyle should have swabs done to rule out asymptomatic infection.

My PCP doesn’t require me to get a yearly pap for a birth control prescription - because for a woman with no history of abnormal paps the current recommendation is a pap every 3 years.

23

Yes, I saw that, although I would bold a different portion:

It says that chlamydia and gonorrhea screening can be done through a urine test OR through a swab. If they meant that to be a urine test or swab for men but ONLY through a swab for women then I have to say that’s not clear at all. The phrasing certainly seems to suggest that a urine test can be used for both men and women.

Even if a cervical swab is the best or only way to test for chlamydia/gonorrhea in women, in my experience this is not a part of an annual pelvic exam anyway. I admittedly don’t have a particularly exciting lifestyle, so perhaps if I were at higher risk for STDs then my doctor would be doing more than just a pap test. But a pelvic exam in and of itself is not enough to make sure that a woman doesn’t have any STDs.

24

Why have I always heard horror stories about the Qtip up the guy 's urethra? Has the urine test always been an option, I can’t imagine many guys would pick the swabbing over the urine test .

25

Here’s the thing - a GYN exam includes a pelvic exam (which doesn’t only check for STDs and excessive bleeding). It’s just part of the routine exam whether you are getting birth control pills or not , much like having your blood pressure taken is part of an exam at a primary care provider even if you are there because your wrist is sore. And my PCP will only renew my cholesterol prescription or my husband’s asthma prescriptions for so long before you guessed it- we have to come in for an exam, which will include having our blood pressure taken even though the needed prescription has nothing to do with blood pressure.

Somehow, it seems that I hear more complaints about gynecologists/exams/birth control than I hear about other similar situations. Sure , someone will complain every so often about the doctor who won’t renew prescriptions without a once a year exam. And people might complain every once in a while about pediatricians who refuse to accept as patients children whose parents are opposed to vaccination. And people complain about needing a new prescription for new glasses or contacts and needing an exam to get that prescription. But not as often as pelvics and BC, and I haven’t seen the providers in those cases called paternalistic, nor do I see quite the level of anger/annoyance when it’s not about gynecologists/pelvics/birth control. The arguments are exactly the same- “It’s my choice” applies to the eye exam, blood pressure check and vaccinations just as much as it does to the pelvic exam , and “The doctor chooses how to practice and which patients to treat” applies to the gynecologist just as much as it does to the PCP,pediatrician or optometrist.

26

The truth is that it varies.

I’ve never found the speculum uncomfortable. I mean, I know it’s there but as long as it warmed up first it’s not a big deal to me. The organ poking is kind of annoying. But the pap smear? Again, not a big deal to me and I’ve never, ever had cramping from it at all.

The slime is yuck, that is very true.

I’m also one of those freaks that aren’t bothered by mammograms. It’s not something I’d seek out for fun, but while they’re annoying and I’m occasionally asked to stand somewhat awkwardly for a bit I’ve never found them painful.

Maybe I’m just insensitive? :stuck_out_tongue:

That said, if another woman tells me one of those exams hurts or causes an issue I don’t doubt it - women are quite variable when it comes to sensitivity and what we find uncomfortable.

27

Too late to edit, but I wanted to mention that I am having back/wrist problems that make it difficult for me to spend a lot of time composing my posts. So I am perhaps not expressing myself as well as I could be, but this is my big point here:

Upthread there are a couple of posts that suggest that a pelvic exam is intended to determine whether a woman has any STDs, and I just wanted to say that this is not the case. A woman could have STDs that would not be detected during her annual pelvic exam.

28

Lamia, I believe they were saying a full STD screening requires a pelvic exam, not that STD screening was the only purpose a pelvic exam served.

29

I work in a sexual health clinic one on one with the staff doctor, and I can tell you that our clinic does not require pelvic exams to prescribe the pill/patch/ring/depo. People are offered STI testing, we encourage testing, but it is not required (unless you are getting an IUD - we do require testing before insertion.)

We will ask about age, weight, smoking, blood pressure, family history for certain cancers and blood clots, history of migraines, what your periods are like (heavy, light, regular, irregular, that sort of thing), immunization history, assess your risk for STIs - but no one is required to have a pelvic.

As far as testing goes, we use urine testing for gonorrhea and chlamydia in both men and women - the catch is (for both men and women again) that you can’t have peed in the last hour before we collect the urine. In fact, if the woman has her period, that is the only way we test.

If you’ve peed, though, men get the urethral swabs (particularly if they have discharge) and women the cervical swabs. Depending on your sexual practices, we will do rectal and throat swabs as well.

The advantage to pelvics is that you can visually check for any lumps, bumps, warts, lesions, etc, and also do a slide to check for yeast, trich, and BV, and a pap, if you’re due.

30

A pelvic exam is a crappy way to determine pregnancy. A pregnancy test is much more accurate.

And, just so the spectrum of experience is shared here…I find both pelvic exams and PAP smears blindingly painful and they trigger panic attacks. Part of it is undoubtedly anxiety with a soupcon of PTSD, but even if you remove my emotional state (which is impossible to do in reality), the physical sensations are far beyond the proclaimed “pressure” or “a little discomfort” and straight into “motherfucking OW!” territory. I’ve never gotten through one without crying in pain and terror. This includes one done as gently as possible with the smallest speculum by my very best friend in the world who I trust more than anyone (she’s a certified nurse midwife).

So yes, it varies…a lot. And the demand for annual pelvic exams are why I went off prescription birth control. My doctor’s pushing me for another PAP (last one was 3 years ago by my friend) and…no. Unless you’re willing to knock me out and rip out my uterus (I’m really not using it anymore), then you’re not sticking a speculum up me ever again. I mean it. I would literally rather die of undiagnosed cervical cancer than go through another PAP.

31

I was on the pill for over 20 years, and I was always required to have a pelvic exam to renew the script.

I really didn’t mind. My doc always made sure her hands and instruments were warm, and she had a trivia poster on the ceiling above the exam table. She must have changed the poster frequently, as I never saw the same one twice. I never had any pain or discomfort during the exams.

She also has the most beautiful waiting room I’ve ever seen. Big, thick, comfy couches and love seats, in a room that looked like a glass porch off an English garden.

32

It’s not malpractice in the UK and it appears to be the same in some parts of the US.

I was on the pill for several years and never had to have a pelvic exam. However, we also don’t have yearly checks for all and sundry like you seem to in the US so there’s no pressure for a doctor to have a woman have her “annual pelvic exam.” We have mandated smear tests after the age of 25 or so (the age depends on where you live) but they’re not yearly unless you had previous abnormal results.

33

There are more complaints about requiring a pelvic exam for birth control than about most other required exams because a pelvic exam is more invasive than, for example, reading an eye chart or having your blood pressure measured, and because it is so obviously unrelated to the scrip requested. As others have said, the relevant medical issues are whether you are already pregnant and things like your blood pressure. The pelvic exam doesn’t even address those issues.

And let’s just say there’s a history of doctors and other authority figures being paternalistic to women about sex.

34

Yeah I was about to say, it’s because the difference is between getting your arm squeezed or poked a bit and having a stranger stick their hand up inside your vagina and take their time feeling around. These are two totally different realms of discomfort.

In my experience it’s about 50/50 whether a doctor will prescribe birth control without a full pelvic and pap smear. I’ve only submitted once under coercion (I needed BC and they weren’t budging) and it was the second worst experience of my life. I really did feel violated.

I’ve experienced the doctor that wanted to give me a full pap/pelvic exam when I was a 17 year old virgin on my period. Right, good job ticking off all the “wrong” boxes there. I’ve experienced going to a GP for an ear infection and the first thing he asks is, “When was your last pap smear?”. I’m goddamn tired of all the fucking pushing. It’s my business whether I get cancer screenings or not, especially when I have 0 risks or indicators for such.

35

This post should be required reading for all med students. Especially the instrument-warming part. The trivia poster is a nice touch!

My doc wants a well-woman exam (Pap + pelvic) for my BC Rx refills, but I don’t really mind because it’s mostly covered by my insurance and I know I “should” but I can see how it’s a real obstacle to reliable birth control for a lot of women.

36

Ditto. Except make that 35 years.

37

I get that the level of discomfort may be different - but that’s a completely separate issue from the “It’s my choice/business” argument which is what I hear people say most often. The discomfort of the exam doesn’t explain why people with complaints about pelvics are less willing to accept " “It’s your choice whether to have the exam and it’s the doctor’s choice about whether to write the prescription without an exam” or why a gyn who won’t write a prescription for BC withour a pelvic is paternalistic while a pediatrician who won’t accept the children of anti-vaccination parents is not.

38

Neither doctor in your examples are working by the guidelines of their specialty organizations, so, yeah, I’d say both are being paternalistic and wrong.

I think it’s been stated pretty well here why people think that pelvic exams shouldn’t be connected to contraception prescriptions: because they don’t give the doctor any information about whether the patient has any contraindications to the pill. And the reason it makes us squeal louder is that’s it’s invasive, uncomfortable and expensive.

If a doctor wanted to check my blood pressure before prescribing an antibiotic, I would likewise think it unnecessary, but it’s a quick painless non invasive test, so I’ll roll my eyes and roll up my sleeve. But the greater the risk, expense and discomfort of a test, the more we need to be certain that it’s warranted before we do it just for the hell of it.

39

No, the level of discomfort of a test directly impacts my willingness to take a test, which is part of the “my choice” part of the argument. If the test otherwise touches on something I’m at risk for, have symptoms for, or at least does not discomfort me, I’ll be willing to do it. The pap/pelvic does not meet that criteria for me. Of course I’m going to be angrier about a test that causes me much distress at no benefit versus a test that at least does not cause me any discomfort.

The amount of women in the usa is a lot higher than anti-vaxxers or people who need glasses in the usa. Given the much larger sample size, even if it’s only a very small portion of upset women versus a lot of upset anti-vaxxers I’ll bet there’s still far more women complaining in numbers. Thus the reason why you hear more women complaining than the other types of groups. And they’re going to be angrier about having invasive tests than someone who just has to go to another eye appointment.

Furthermore, I don’t think a doctor should ever withhold needed medicine (I say “need” in the sense that we live in a modern society and access to reliable BC is a basic standard for a modern society) from a person who is proven to be completely eligible to take it. Excepting if it poses some risk to the doctor’s own health (anti-vaxxers could be this).

40

You can ask for one of the pediatric size speculae - they come in small, medium and horse-lover.