A question of standards of care?

1. Greetings All Nurses,
   I have asked several questions and now I have an other one. These excerpts are from an article originally http://www.arhp.org/clinical/greatdebate.htm
   
   Titled:
   

   Originally posted at the ARHP web site:
   <STRONG>
   
   DRS. DAVID GRIMES AND RICHARD HAUSKNECHT DEBATE WHETHER A PHYSICAL EXAM AND PAP SMEAR SHOULD BE "BUNDLED" WITH THE PROVISION OF ORAL CONTRACEPTIVES
   
   Dr. Grimes I would like to describe a rationale for unbundling, uncoupling, preventive health care services for women. How many abortion providers have done abortions on women who could not get in for their annual exam or Pap smear, or chose not to do so? Almost all of us. In my career of over 25 years of doing abortions, every time I encountered a woman such as this I felt remorse and guilt, knowing that I was indirectly responsible for her being in this situation because early in my career I helped establish these barriers that helped women fall pregnant against their wishes. How many of these obstacles are really necessary? I am now spending the latter half of my career trying to take down these barriers.
   
   As preparation for this presentation, I turned to that venerable source of all medical wisdom, the Physician's Desk Reference, and according to officially approved labeling there are nine absolute contraindications to use of birth control pills: (1) thrombophlebitis or thromboembolic disorders; (2) a past history of deep vein thrombophlebitis of thromboembolic disorders; (3) cerebral vascular or coronary artery disease; (4) known or suspected carcinoma of the breast; (5) carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia; (6) undiagnosed abnormal genital bleeding; (7) cholestatic jaundice of pregnancy or jaundice with prior pill use; (8) hepatic adenomas or carcinomas; and (9) known or suspected pregnancy.
   
   That's all of them. That's it. These are absolute contraindications, although I don't happen to agree with all of them. But by my count, one out of those nine absolute contraindications might be picked up by a pelvic exam-pregnancy. But are there alternative ways of detecting if someone is pregnant already? Well, I hate to sound like a curmudgeon, but if you take a decent history, often you do not need elaborate laboratory tests or invasive procedures. Or if you don't want to do that, I can do pregnancy tests that are exquisitely sensitive for $2.00 where I practice. So you don't need to subject someone to a pelvic exam to determine if they are pregnant. Indeed these means may be more sensitive than is the physical examination in detecting pregnancies below six weeks gestational age.
   </STRONG>

   
   
   This Doctor is advocating a reduction in a standard of care that he even missed the piont. One that the clients he is serving do not get the care they so much need like a yearly Pap for preventive health. And two that the PDR specifically containdicates oral contraceptives for women with a

   From this article, Dr. Grimes, and the PDR:
   <STRONG>
   (5) carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia;</STRONG>

   
   
   Correct me if I am wrong but Breast Cancer is a estrogen-dependant neoplasia and a clinical breast exam is one method of finging a sign of the pathology? In addition a cervical Pap smear will find a wndometrium pathologiacl process that would contrindicate the use of the pill, also? Now I am totally confused he is advocating an abolishment of the Pelvic exam prior to prescribing the pill. Why that will set women's health back decades and indanger women who have this standard of care applied to their care, right? Maybe I am missing something but I think his agenda is to left wing? Looking for responses!
   All POV please!
   
   
   Peace,
   Have a Blessed Day,
   Jami
2. 

   About jamistlc

   Joined: Apr '01; Posts: 340; Likes: 9
   DOULA / NURSE LPN HIV/AIDS Educator

   5 Comments

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3. 
   Jun 22, '01

   Occupation: Army Nurse Midwife Joined: Apr '00; Posts: 29; Likes: 10

   OK everyone, my two cents in this old debate.
   
   One of the major reasons to require an annual exam for the Rx of OPCs is that, for many women, this is the ONLY well women care they receive. The exam consists of more than just a pap smear, it includes a full physical.
   
   I disagree that an annual exam is a particular barrier to contraceptive use (one hour, once a year!) - bigger barirres are the myths surrounding OCPs, the lack of OCP coverage by many health insurance policies, and the misuse of OCPs.
   
   Persons on medicare/aid/welfare and various other programs get the exam and OCPs at no cost.
   
   I think the "morning after pill" should be readilly avalible over the counter, as there is little to no risk - even for the smoker.
   
   Yes, the PDR lists the absolute contradictions; however, there are relative contradictions - especially for smokers over 35. that is not included in the PDR, nor does it include evidence or references. The PDR is printed by the pharm companies, and is basically "politically correct".
   
   Two better resourses for information on OCPs are Hatcher's "Contraceptive Technology" or Dickey's "Managing Contraceptive Pill Patients." These are the definitive "bibles" on the subject.
   
   
   ANYWAY - like i said - my two cents
   
   PAC, RNC CNM, presently in an innercity Chicago women's health clinic
   
   
   PS sorry about my spelling..........
4. 
   Jun 23, '01

   Joined: Jul '00; Posts: 11,351; Likes: 387

   I think you'd be surprised at how many younger women don't want the pap smear and to avoid it either use condoms or nothing at all. I don't think this is a requirement here anymore. I know that women can get Rxs for injectable contraception like Depo, so I am not certain as to why they have to get an exam for oral contraceptives.
5. 
   Jun 23, '01

   Occupation: Army Nurse Midwife Joined: Apr '00; Posts: 29; Likes: 10

   Even depo users have a yearly exam usually
   
   As for the younger women who do not want a pap - unfortunetly, if they are sexually active, the chances are they have already picked up the HPV virus, some 5 strains of which have been proven to cause cervical cancer.
   
   We are finding more and more relativly young women with the early cervical changes which can eventually lead to cervical cancer - most of which we pick up during pregnancy exam - of which the PAP is a part of.
   
   Many times this is their first PAP
6. 
   Jun 30, '01

   Occupation: OB nurse, MSN student Joined: May '01; Posts: 364; Likes: 8

   I never knew that there were so many things out there and so frequently until I started working the OB side. I think with teens there are some delicate issues out there that would influence Contraception methods. Depo- great because they won't forget it but sometimes if they gain a lot of weight they may not return for their next dose. Orals- may forget. If they do think they are pregnant I have seen a few take a whole box at once. But either way it promotes unprotected sex and annul exams really do need to be done. Many patients may not feel it is important because they do not know the reasoning. I usually find patient chatting instead of patient teaching to work better. Let them know why and make them a part of the exam. The younger generation seems to want to be in control so let them.
   Jared
7. 
   Sep 29, '10

   Occupation: Army Nurse Midwife Joined: Apr '00; Posts: 29; Likes: 10

   9 years later and how things have changed!!!! HPV vaccinations, Paps every 2-3 years, No Colpo for LGIL or ASCUS under 20,
   
   So we now are working on a mechanism to be able to refill BC for more than 1 year...

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