OCPs held hostage to annual paps? STILL?!

[rev ronin]

Saw a young lady in walk in today, needed her OCP refilled.  Scheduling was her only issue, since she was having no problems and had a benign history, so I wrote for #84 with three refills.  She was shocked--she was expecting a mere month, because her women's healthcare provider would only issue another year's OCP after an annual exam including pap.

 

I was floored.

 

Are we still in the 1990's?  At what point does requiring annual screening, against multiple consensus guidelines, become unethical?

 

How many of you are still encountering providers who are mandating annual pap+pelvic?

[sk732]

I'd be interested to know if the women's health provider was a guy...could be something shady going on.  At best, there is something not right going on, as it would seem someone isn't attending any CME, reading bulletins, etc - perhaps the practitioner concerned has no Give A Frig Factor left and since they weren't part of the consensus, why would they be party to it's guidelines - after all they're merely guidelines right?  (we need a sarcasm emoji for here)

 

On a purely Devil's Advocate side though, there could also be a patient compliance issue with other things going on you're unaware of - had that sort of thing happen in the past.

 

I have to say that there were many sighs of relief and not so silent "Woohoo's" in my old family practice when our provincial guidelines changed.

 

SK

[Avalon]

This right here is the key to your post (in my opinion as a women's health PA):

 

        since she was having no problems and had a benign history

 

Let me ask, How would you have known this had she not come for an office visit?  

 

I recently saw a patient who had been prescribed combined oral contraceptives by a colleague of mine for the past few years. She was now several months overdue for her "annual exam" (which is, admittedly, a misnomer because it need not necessarily be "annual" and it need not include a pelvic "exam").  She had remained on COCs by calling in for a few refills while her annual exam was pending.  Unlike your patient, this young woman did not have a benign history.  In the past several months she had developed debilitating migraines with aura that included visual loss and facial numbness.  Needless to say, she is now off COCs and has had a Mirena placed.  

 

A lot can happen in a year, both in the patient's medical history as well as in the patient's family history, that may impact contraceptive management, and I want to know this information before I continue to prescribe a drug combination associated with a four fold elevation in VTE risk.  In another recent case, we learned at an annual exam that a patient's otherwise healthy 27 year old brother died of a PE.  This patient was then worked up for coagulopathy and found to have two mutations (MTHFR and Factor V Leiden).  I carry the MEC wheel in my coat pocket and use it to educate and inform patients about contraceptive choices.  

 

Just my thoughts...

[rev ronin]

I don't mind requiring an annual visit; I do that for any patient on any medication getting refills, and one year is only for healthy people with stable conditions.

 

The issue I have a problem with is required yearly paps--it's not standard of care, it's invasive, and the expected discomfort keeps too many women away from preventative care. I have no problem with a provider offering them, as I know some female patients who expect them (although I suspect that is somewhat a variant on Stockholm Syndrome). Recommending a yearly pap for asymptomatic screening in a patient without history of previous abnormal paps or HPV infection is not standard of care, and *requiring* one is, as far as I can see, medically indefensible.

 

Every countermeasure has a cost--every surgery, every drug, every rads study.  Sometime the cost is a lot more obvious, but every unnecessary and pointless study, even the cheap and not uncomfortable ones, is a waste of provider and patient time that can and likely *should* be spent on higher-yield activities.  EBM-driven consensus guidelines should shape general practice, and individual patient needs should drive exceptions.