BIMANUAL PELVIC EXAMINATIONS: TEMPORAL TRENDS AND IMPOSED BARRIERS TO SELF-ADMINISTERED HORMONAL CONTRACEPTION USE

Brief Description: Screening bimanual pelvic examinations (SPEs) have questionable benefit and can lead to psychological harms and unnecessary surgery due to false positives. SPEs do not lead to safer or more effective self-administered hormonal contraceptive (SAHC) use, and fear or discomfort with SPEs may cause young women to postpone obtaining SAHC. Nevertheless, many providers and patients still consider SPEs a prerequisite to SAHC use. This dissertation addressed three critical gaps in knowledge about SPEs. In Aim 1, we assessed temporal trends in SPEs from 2012-2019. In Aim 2, we conducted a series of one-on-one interviews with patients who used SAHC and providers who regularly prescribed SAHC to explore experiences and perceptions of SPEs in general and in relation to SAHC use. In Aim 3, we used medical and prescription claims to document the difference in prevalence of SPEs at a preventive care visit among those who filled a prescription for SAHC before or after a preventive care visit compared to those who did not. Summary of Conclusions: Our findings suggest that neither the 2013 evidence report nor the 2014 American College of Physicians guideline change, recommending against SPEs, altered the overall trend in monthly rates of SPEs from 2012 to 2019. We also found that patients were often unaware of reasons for SPEs. Patients found pelvic exams generally invasive and uncomfortable, and this discomfort may be mitigated by a strong relationship with their provider, having a female provider, and with thorough communication during the pelvic exam. Many providers still routinely conducted SPEs, and Papanicolaou tests and sexual activity often prompted providers to conduct SPEs, although neither of these reasons is based on current evidence or recommendations. Although many providers stated they did not consider SPEs to be a requirement for SAHC prescription, many noted that they frequently conduct a SPE at the time of SAHC prescription because it coincides with an annual visit. Finally, we found a higher prevalence of SPEs at preventive care visits among SAHC users vs. SAHC non-users. Together, these findings suggest that SPEs may be over-used in clinical practice, generally and specifically in relation to SAHC prescribing.