National Partnership for Women & Families

Monthly Women's Health Research Review

Association Between Adolescent Pelvic Exam and Contraceptive Use Dropping Amid Changes to Cervical Cancer Screening Guidelines

Summary of "Cervical Cancer Screening, Pelvic Examinations, and Contraceptive Use Among Adolescent and Young Adult Females," Vinekar et al., Journal of Adolescent Health, May 25, 2015.

"Indications for conducting pelvic examinations among adolescents have decreased considerably over the last decade," sparking concern that such a decline "may have unintended consequences on the delivery of other recommended reproductive health services, including contraception provision and [sexually transmitted infection] screening," Kavita Vinekar, of the Program on Women's Health Care Effectiveness Research at the University of Michigan Medical School's Department of Obstetrics and Gynecology, and colleagues wrote.

According to the authors, the decline in adolescent pelvic exams could be linked to changes in cervical screening guidelines in 2008, as well as "the increased availability of urine-based assays for [STI] screening." The authors explained that the revised guidelines delay routine screening until age 21, "regardless of sexual activity," whereas previously, they called for "routine screening starting 3 years following the onset of sexual intercourse."

The authors assessed "the association between pelvic examination and adolescent contraceptive method use in two time periods" to determine whether that relationship "among female adolescents had changed after the release of guidelines ... and recommendations that should decrease the frequency of screening pelvic examinations in this population."

Methods

For the study, the authors used data from the 2006-2010 National Survey of Family Growth. Specifically, they assessed "the subpopulation of [1,208] post-menarchal adolescent (aged 15-20 years) female participants at risk for an unintended pregnancy."

Vinekar and colleagues defined the primary "exposure ... as receipt of either a pelvic examination and/or a Pap smear in the past 12 months." Their primary outcome was whether study participants were using "highly effective [contraceptive] methods (tubal ligations, intrauterine contraception, implants), effective methods (contraceptive pills, Depo-Provera, patches, ring), other methods (barrier methods, withdrawal, periodic abstinence), and no method," although they combined "current use of effective or highly effective methods" in their final analysis due to low use of highly effective methods.

The authors hypothesized that "the association between pelvic/Pap and contraception use should decrease over time if new clinical guidelines are adopted," so they assessed the relationship between such exams "and effective or highly effective contraceptive method use in two time periods: June 2006-May 2008 (Period 1) and June 2008-May 2010 (Period 2)."

Meanwhile, the authors "expected that exposure to health services generally ... might be associated with both [the] exposure (pelvic/pap) and [the] outcome (effective or highly effective contraception use)," so they "conducted a subanaylsis of adolescents [who] reported ever using any medical service since menarche."

Results

Vinekar and colleagues found that 57.3% of the 1,208 study participants "reported that they had a pelvic examination and/or Pap smear in the preceding 12 months."

According to the authors, "[a]ge correlated significantly with the receipt of a pelvic/Pap" -- with older adolescents ages 17-18 and 19-20 more likely to have received an exam in the past 12 months than younger adolescents -- while "[r]ace and socioeconomic status were not associated with receipt of pelvic/Pap." They found that "[a] larger proportion of adolescents who had received a pelvic/Pap in the past 12 months were using effective or highly effective methods of contraception [56.9%] than those who had not received pelvic/Pap [25.4%]."

The researchers noted that 565 adolescents were interviewed in Period 1 and 643 were interviewed in Period 2. "The proportion of adolescents reporting using effective or highly effective methods of contraception was higher in Period 2 than in Period 1," although "[o]ther measures of health service use did not differ significantly by study period," they wrote. Overall, they found that "[r]eceipt of pelvic/Pap in the past 12 months was associated with use of effective or highly effective contraception in the whole study population and in [the] subpopulation of adolescents reporting at least one health service visit since menarche." When the authors controlled for variables such as "health service use, pregnancy history, and demographic characteristics," they still found that "the odds of effective contraception use were higher among adolescents who had received a Pap/pelvic examination in Period 1," though "effective contraception use was not related to pelvic/Pap in Period 2."

Discussion

The authors found that in Period 1, "the odds of using an effective or highly effective birth control method among sexually active female adolescents were three times higher among those who reported having a pelvic examination with or without a pap smear as compared with those who did not." Nonetheless, they also noted that the association "may have weakened," as effective contraception use "was no longer associated" with pelvic examination receipt during the second period.

The authors said the finding "provides some reassurance" that the screening revisions "may not negatively impact" effective contraception use. However, they noted that the finding could be related to early adopters of the guidelines potentially being "more likely to address contraception use with their adolescent patients" and, therefore, urged "continued monitoring."

Further, the authors "found no difference in use of counseling, screening for STIs, or pelvic examinations with or without a pap smear across later years in the last decade," but they added that "reproductive health service use among adolescents remains exceedingly low, especially among subgroups such as socially disadvantaged adolescents." According to the authors, "[t]his observation partially explains contraception nonuse and reliance on less effective methods by some adolescents" and affirms the need to "address low reproductive health service use among adolescents at risk for unintended pregnancy."

They concluded, "Although our findings on the apparent decreasing link between pelvic exams and receipt of effective contraception are reassuring, it seems plausible that as clinical practice continues to change around the screening pelvic examination, consequent changes in utilization of reproductive health services among adolescents, both in frequency and in source of services, warrant continued monitoring, particularly as they may shape reproductive outcomes."