ONTD Political

Holding Birth Control Hostage

7:30 pm - 04/30/2012
Doctors still require women to submit to cancer screenings and pelvic exams to get birth control pills. Scientists say that shouldn't happen.


Recently, my doctor gave me an ultimatum: Come in for a pelvic exam, or I won't refill your birth control pills. The problem arose after I tried to get my prescription refilled before going on vacation in March, only to be told that the doctor's office wouldn't sign off on the refill because it had been a year and one month since I'd had an annual exam and a Pap smear. A nurse grudgingly gave me a monthlong reprieve if I promised to come in for an exam when I returned from my trip.

I really, really didn't want to go in for an exam. I've had two kids, a false positive Pap test and all the ensuing misery that comes with it, and spent enough time in the stirrups to last a lifetime. All I really wanted were my pills; I was pretty sure the exam could wait another year or more.

The science was on my side.



Just a few weeks earlier, the US Preventative Services Task Force, an independent group of national experts that makes evidence-based health care recommendations, released new guidelines declaring definitively that women over 30 don't need a Pap smear more than once every three years unless they have a couple of risk factors, which I don't have. The American Congress of Obstetricians and Gynecologists has said that birth control pills can safely be prescribed without a full-on exam.

Doctors, though, don't seem to be in any hurry to give up old habits. After I got back from vacation, I emailed my doctor, citing the new guidelines, and asked if he could give me a new one-year prescription for birth control pills without a pelvic exam. He wrote back, "Yes, one can argue about whether or not you need a pap, but current recommendations are still for an annual exam, blood pressure readings, updating family history, ('torturous pelvic exam,' I'm afraid), etc. So I would still like you to come in. See you soon?"

The doctor had me over a barrel. As it turns out, my experience isn't unique. Doctors regularly hold women’s birth control prescriptions hostage like this, forcing them to come in for exams that research is increasingly showing are too frequent and often unnecessary and ineffective. A 2010 study published in the journal Obstetrics & Gynecology found that 33 percent of doctors always require a pelvic exam and Pap smear for a hormonal contraception prescription, and 44 percent regularly do so, even though there's no medical reason for linking the two.

Indeed, there's a growing body of evidence that the entire annual ob-gyn exam, with the mandatory and miserable pelvic exam where doctors poke around one's uterus and ovaries with their fingers, is largely obsolete. For instance, there's no evidence that doctors can diagnose ovarian cancer with a pelvic exam in women showing no symptoms. A clinical trial found that doctors were unable to identify any cancers in test subjects by pelvic exams alone, and the National Cancer Institute no longer recommends the tests for postmenopausal women. Even chlamydia screenings, which are recommended for women under 26 and those at higher risk for the sexually transmitted disease, can be done by simply having women pee in a cup, and don't require an invasive and expensive exam.

The scientific basis for much of the traditional well-woman ob-gyn annual check-up is so slim that "the routine pelvic examination may be an example of more service leading to worse outcomes," Dr. Carolyn Westhoff, an ob-gyn at Columbia University, wrote in the Journal of Women's Health last year.

Indeed, all this excess treatment has serious negative effects. Mandatory pelvic exams often deter women from seeking contraception in the first place. Failing to get contraception puts women at risk for the much more likely problem of an unwanted pregnancy, which is far more dangerous than getting birth control pills without a pelvic exam.

Despite not being very good at detecting cancer, annual pelvic exams are great at turning up stuff that if left alone would never cause a problem—things like noncancerous fibroids and ovarian cysts the patient never noticed. Discovery of such "problems" in exams usually leads to a surgical intervention. "The clinical trial data show no evidence that pelvic examination improves the early detection of ovarian cancer or diagnosis of other conditions in women who have no symptoms," Westhoff says. "Overuse of the pelvic examination contributes to high healthcare costs without any compensatory health benefit."

Westhoff and her colleagues suggest that the mandatory annual pelvic exam is one reason American women have twice the rate of hysterectomies as their European counterparts. And the Pap smear, of course, has its own issues with false positives, which can be as high as 10 percent. One of the treatments often recommended after a positive result can double the risk of a premature delivery for women who go on to get pregnant.

Getting a false positive is no walk in the park, either. About a year and a half after the birth of my second child, I had an IUD put in for contraception, which isn't a fun procedure and is also very expensive because much of it isn't covered by insurance. A few months later, I had to go in for the requisite annual exam. My Pap test came back with problems. So I had undergo a really painful and ultimately negative endometrial biopsy, which couldn't be done without taking out the IUD I'd just had put in. Not only was I out hundreds of dollars, I also spent a week or two stressing out that I might be headed for chemo, hair loss, and dying before my children get to high school. The psychic trauma from unnecessary tests is real.

"It's harder to get doctors to quit doing certain things" than to embrace new procedures, says Shannon Brownlee, a health policy expert at the New America Foundation who wrote a book about overtreatment in America. Part of the problem, she says, is that the primary way doctors learn about new science is through continuing medical education, which they have to do to keep up their medical licenses. Most continuing medical education is funded by drug and medical device companies.

"'Don't do it' is not a message that the drug industry and the medical device industry is all that excited about," Brownlee says. Guidelines from the government trickle down very slowly to doctor's practices. And patients raise these issues at their peril, Brownlee notes. "When you have that conversation with your doctor, you often get labeled as a noncompliant patient." The health care system is also plagued with irrational incentives that reward doctors for doing more rather than less, even when it's in the patient's best interest to be judicious. Doctors need to keep their waiting rooms full to keep their practices open.

There is one way to change the system: Make the Pill an over-the-counter (OTC) drug. If women could get birth control pills from a pharmacy, like they do in other countries, and could decide for themselves whether they should have a pelvic exam every year, the country could experience serious health care savings. Unnecessary health care treatment overall is estimated to cost at least $158 billion a year.

The FDA has been considering making the Pill available without a prescription at least since 1993. But with the recent debates about health care reform and the contraceptive mandate in the new health care law, the issue has come to the forefront again with new urgency. The Pill is one of the safest regularly used drugs on the market. Not surprisingly, though, the American Congress of Obstetricians and Gynecologists hasn't signed on to the campaign, no doubt because of the prevailing view in the profession that if women could get their pills without a prescription, they wouldn't come in for annual checkups.

Prominent ob-gyns Michael Cackovic and Michael Paidas, writing in the journal Modern Medicine, reflected this view in a 2008 op-ed against the OTC pill, writing, "women who [get] OTC pills could have little motivation for annual exams, sexually transmitted infection screening or Pap smears, which could possibly manifest as less screening for cervical cancer."

Theirs is a common and paternalistic view of women patients. After all, men are never required to, say, have a colonoscopy as a condition of getting blood pressure medication, Viagra, or even a vasectomy, even though men are much worse about going to the doctor and getting checkups than women are.

Women don't need to have their birth control pills held hostage to get needed cancer screenings. That's not just my opinion. There's hard data to prove it. In many places in the world, the pill is already available over the counter, so some smart researchers have taken a look at the behavior of women who get it that way.

Dr. Daniel Grossman, an ob-gyn and senior associate at Ibis Reproductive Health, coordinates a working group pushing to make the Pill available without a prescription. With colleagues at the University of Texas, Grossman has studied women in Texas who are able to get the Pill from pharmacies in Mexico without a prescription. As it turns out, the women who make the trip, he says, "had very high rates of getting all the preventive screening tests, higher than the national average." Not only that, but women who got their pills without the hassle of an exam were much more likely to stay on the Pill continuously, a factor that research shows is directly related to fewer abortions and unplanned pregnancies.

Still, the Pill wasn't going to be available over the counter soon enough to solve my problem. Fortunately, I discovered that there is one health care provider that's a pioneer in disconnecting birth control pills from mandatory pelvic exams: Planned Parenthood. So I went there.

Passing through the bullet-proof, bomb-proof entrance to the DC clinic was a little unnerving; while I sat in the waiting room watching The View with a bunch of young women and solo men, I got slightly paranoid about errant bullets or bombs from anti-abortion nuts. But the visit turned out to be painless. After I filled out a lot of paperwork asking about my medical history, a nurse took my blood pressure—which, unlike a pelvic exam, is actually related to the potential risks of the Pill—asked me some questions about my history, and then wrote me a prescription. And unlike my doctor, she even offered to write it so that I could get three packs at a time instead of one.

Without insurance, the visit would cost $130, which isn't cheap, but it's still likely to be much cheaper than a full-on pelvic exam and all the related lab work. (Planned Parenthood also charges on a sliding scale, so the cost can be less depending on income.) It was worth it, mainly because I got my prescription without having to take my clothes off. And in a year, I might go back for a checkup with a doctor. But if I do, it will be because I think it's the right thing to do, not because I don't have a choice.


Source

I tried bolding it the best I could since it's a long article
lavenderfrost 1st-May-2012 12:56 am (UTC)
Despite not being very good at detecting cancer, annual pelvic exams are great at turning up stuff that if left alone would never cause a problem—things like noncancerous fibroids and ovarian cysts the patient never noticed.

As someone w/Polycystic Ovary Syndrome? FUCK YOU. I'd say that bleeding myself half to death for weeks on end whenever I have a goddamn period counts as a fucking Problem.

I love the idea of birth control being over-the-counter, and agree that docs who withhold it for the sake of getting you in for an unnecessary exam should be FIRED, but getting one periodically is still a good thing. They're not as useless as she's trying to make them sound.
bellichka 1st-May-2012 01:29 am (UTC)
I think what the article is saying pertains to cysts with no other symptoms. You, obviously, have had other symptoms, that would turn up without the exam, but some have no symptoms. I totally understand where you're coming from, though :(
mollywobbles867 1st-May-2012 01:37 am (UTC)
WTF. I missed that part. I have PCOS too and my ovarian cysts cause fucking problems! My gyno was so worried last year since I hadn't been on BC in years that she did a biopsy. Also, I fucking notice. You know, those ovarian cysts cause things like: making it hard to lose weight, abnormal hair growth, 11 day long periods (I'm lucky because some women with PCOS bleed for months & nothing helps), etc. Oh, then there was this year when I had a weird black spot on my nipple and had THAT biopsied just in case.

Yeah, I hate it when people make them seem useless because they feel pretty damn useful to me. For a woman who has a perfect period and doesn't have any issues yet and isn't that old, a yearly may be too much, especially just to get BC. But they are not inherently useless. I am on my period right now and I had a cramp earlier that almost made me pass out...even after I had taken Midol.

Edited at 2012-05-01 01:38 am (UTC)
evilegg 1st-May-2012 01:53 am (UTC)
What information does the doctor get during a pelvic exam that helps treat PCOS? Did you have symptoms before being diagnosed?
mollywobbles867 1st-May-2012 02:28 am (UTC)
Well, since I'm more susceptible to endometrial cancer, pelvic exams can detect that. It's not so much the PCOS itself, but the risks it puts me at. I am also at an increased risk for breast cancer, but obviously that has nothing to do with a pelvic exam, it's just done at the same time.
crysania4 1st-May-2012 01:55 am (UTC)
I didn't think the article was saying they're useless, just that they're overdone for women who have no problems. As someone who thankfully has no problems (except for the time I had an abscess in about the worst possible place a woman could have one), I don't feel like I need an exam every year. For other women who have PCOS or other problems, they ARE damned important.
liret 1st-May-2012 03:33 am (UTC)
ovarian cysts the patient never noticed.

More then 3/4 of cysts never cause symptoms and are not related to a health risk - and routine pelvic exams can't tell the difference between a problem cyst and a harmless one. I'm not sure why you're reading an insult to cyst-related health problems - which I have, though pelvic exams will come up as 'nothing wrong' even at the worst of my symptoms - from this.

And I'm not sure what exactly you're saying, but if you mean that they aren't useless because they can detect PCOS - no, they can't. They can be one of several tests to confirm/rule out a problem, but the article is very specifically talking about them not being necessary yearly - instead of every two or three years - for women with no health symptoms or risk factors. No one's saying to stop doing them entirely.
lavenderfrost 1st-May-2012 06:21 am (UTC)
annual pelvic exams are great at turning up stuff that if left alone would never cause a problem—things like noncancerous fibroids and ovarian cysts the patient never noticed.

3/4 of the time =/= never. If she'd said they rarely cause a problem, that's one thing. But writing off something that *can* be serious as a non-issue? Not cool. That's mostly what I took issue with.
mirhanda 1st-May-2012 06:43 pm (UTC)
I still think your reading this through your rage and not really understanding what it's saying. It's not talking about women like yourself who have symptomatic ovarian cysts. It's talking about women who have an ovarian cyst and nothing else is wrong and they don't even know and have no symptoms.

Edited at 2012-05-01 06:45 pm (UTC)
nonnycat 1st-May-2012 09:13 am (UTC)
Saying as another person with PCOS--

Polycystic ovarian syndrome is not the same thing as your run of the mill ovarian cysts. The PCOS cysts are basically microcysts, there are lots of them, and they don't show up on paps. It's also a full blown syndrome and there's chicken-and-egg question of whether it's insulin issues that cause it or the cysts or hormones or what. They really don't know for sure.

A lot of ovarian cysts don't cause issues, and usually, even IF you are having regular paps, a doc isn't going to do anything more than a "wait and see" approach if they discover a cyst unless you're having symptoms. And really, at that point, you probably are better off just going in and having stuff checked out if you start to have a problem.
keestone 1st-May-2012 01:20 pm (UTC)
To my understanding, there's a difference between having an ovarian cyst (which is often harmless) and having PCOS. (I'm another one with the latter anyhow.)
mirhanda 1st-May-2012 06:41 pm (UTC)
But for you, I think the symptom was the excessive bleeding. The article is talking about women who don't have any symptoms.
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