Most women can safely be prescribed oral contraceptives without undergoing a pelvic examination, according to guidelines by the American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization. Yet about a third of clinicians who provide family planning services report that they always perform a pelvic examination-and nearly half usually do-according to researchers at the University of California, San Francisco. Requiring a pelvic examination adds an unnecessary hurdle to obtaining birth control.

The researchers surveyed 1,196 U.S. obstetrician-gynecologists, family physicians, and advanced practice nurses (APNs) who specialize in family medicine or women's health. Rates of pelvic examinations were lowest among women's health APNs, with only 17% always performing one, compared with 29% of obstetrician-gynecologists, 33% of family physicians, and 45% of family medicine APNs. Physicians in private practice were twice as likely as those working in community or family-planning clinics to always require a pelvic examination. Rates were also higher among older clinicians, those working in the South, and those seeing a high number of Medicaid patients. The study's findings point to "the need for targeted continuing education, particularly with older clinicians in private practice who are the furthest from their medical training and perhaps from professional networks and incentives for updating protocols," write the authors.

"We should have as few barriers as possible to women trying to get effective birth control," says George F. Sawaya, an obstetrician-gynecologist and a study coauthor. He doesn't have an explanation for why family medicine APNs perform nearly three times more pelvic examinations than APNs at women's health clinics.

"Various health professionals have different standards to which they adhere, depending on the practice setting," he says.

ACOG recommends that pelvic examinations start at age 21 and that women get them every other year until age 30, after which low-risk women can be screened every three years. Even when sexually transmitted infections are suspected, urine-based tests are more cost-effective and beneficial than speculum screening. The unintended consequence of requiring pelvic examinations is that "some women may opt for less-effective methods, such as condoms," says Sawaya.-Carol Potera