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Original Investigation
Less Is More
January 6, 2020

Prevalence of Potentially Unnecessary Bimanual Pelvic Examinations and Papanicolaou Tests Among Adolescent Girls and Young Women Aged 15-20 Years in the United States

Author Affiliations
  • 1Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
  • 2Reproductive Statistics Branch, National Center for Health Statistics, Division of Vital Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
  • 3Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
  • 4Center for Healthcare Value, University of California, San Francisco
JAMA Intern Med. 2020;180(2):274-280. doi:10.1001/jamainternmed.2019.5727
Key Points

Question  What is the prevalence of potentially unnecessary bimanual pelvic examinations and Papanicolaou tests among US women aged 15 to 20 years?

Findings  In this population-based, cross-sectional study using data from 2011 to 2017, an estimated 2.6 million women aged 15 to 20 years in the United States (22.9%) received a bimanual pelvic examination in the past year, and 54.4% of these examinations were potentially unnecessary. An estimated 2.2 million young women (19.2%) received a Papanicolaou test in the past year, and 71.9% of these tests were potentially unnecessary.

Meaning  The findings suggest that many young women receive potentially unnecessary bimanual pelvic examinations and Papanicolaou tests.


Importance  Pelvic examination is no longer recommended for asymptomatic, nonpregnant women and may cause harms such as false-positive test results, overdiagnosis, anxiety, and unnecessary costs. The bimanual pelvic examination (BPE) is an invasive and controversial examination component. Cervical cancer screening is not recommended for women younger than 21 years.

Objectives  To estimate prevalence of potentially unnecessary BPE and Papanicolaou (Pap) tests performed among adolescent girls and women younger than 21 years (hereinafter referred to as young women) in the United States and to identify factors associated with receiving these examinations.

Design, Setting, and Participants  A cross-sectional analysis of the National Survey of Family Growth from September 2011 through September 2017 focused on a population-based sample of young women aged 15 to 20 years (n = 3410). The analysis used survey weights to estimate prevalence and the number of people represented in the US population. Data were analyzed from December 21, 2018, through September 3, 2019.

Main Outcomes and Measures  Receipt of a BPE or a Pap test in the last 12 months and the proportion of potentially unnecessary examinations and tests.

Results  Responses from 3410 young women aged 15 to 20 years were included in the analysis with 6-year sampling weights applied. Among US young women aged 15 to 20 years represented during the 2011-2017 study period, 4.8% (95% CI, 3.9%-5.9%) were pregnant, 22.3% (95% CI, 20.1%-24.6%) had undergone STI testing, and 4.5% (95% CI, 3.6%-5.5%) received treatment or medication for an STI in the past 12 months (Table 1). Only 2.0% (95% CI, 1.4%-2.9%) reported using an IUD, and 33.5% (95% CI, 30.8%-36.4%) used at least 1 other type of hormonal contraception in the past 12 months. Among US young women aged 15 to 20 years who were surveyed in the years 2011 through 2017, approximately 2.6 million (22.9%; 95% CI, 20.7%-25.3%) reported having received a BPE in the last 12 months. Approximately half of these examinations (54.4%; 95% CI, 48.8%-59.9%) were potentially unnecessary, representing an estimated 1.4 million individuals. Receipt of a BPE was associated with having a Pap test (adjusted prevalence ratio [aPR], 7.12; 95% CI, 5.56-9.12), testing for sexually transmitted infections (aPR, 1.60; 95% CI, 1.34-1.90), and using hormonal contraception other than an intrauterine device (aPR, 1.31; 95% CI, 1.11-1.54). In addition, an estimated 2.2 million young women (19.2%; 95% CI, 17.2%-21.4%) reported having received a Pap test in the past 12 months, and 71.9% (95% CI, 66.0%-77.1%) of these tests were potentially unnecessary.

Conclusions and Relevance  This analysis found that more than half of BPEs and almost three-quarters of Pap tests performed among young women aged 15 to 20 years during the years 2011 through 2017 were potentially unnecessary, exposing women to preventable harms. The results suggest that compliance with the current professional guidelines regarding the appropriate use of these examinations and tests may be lacking.

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