Gynecological health and uptake of gynecological care after domestic or sexual violence: a qualitative study in an emergency shelter.

BACKGROUND: Domestic and sexual violence have been linked to adverse gynecological and obstetric outcomes. Survivors often find it difficult to verbalize such violence due to feelings of shame and guilt. Vulnerable or socially excluded women are frequently excluded from research, particularly qualitative studies on violence. This study aimed to characterize the perceived impact of domestic or sexual violence on the gynecological health and follow-up among women with complex social situations. METHODS: We analyzed the data following inductive thematic analysis methods. RESULTS: Between April 2022 and January 2023, we conducted 25 semi-structured interviews, lasting on average 90 min (range: 45-180), with women aged between 19 and 52, recruited in an emergency shelter in the Paris area. The women described physical and psychological violence mainly in the domestic sphere, their altered gynecological and mental health and their perception of gynecological care. The levels of uptake of gynecological care were related to the characteristics of the violence and their consequences. The description of gynecological examination was close to the description of coerced marital sexuality which was not considered to be sexual violence. Gynecological examination, likely to trigger embarrassment and discomfort, was always perceived to be necessary and justified, and consent was implied. CONCLUSION: This study can help question the appropriateness of professional practices related to the prevention of violence against women and gynecological examination practices. Any gynecological examination should be carried out within the framework of an equal relationship between caregiver and patient, for the general population and for women with a history of violence. It participates in preventing violence in the context of care, and more widely, in preventing violence against women.

Tampon loss - management among adolescents and adult women.

The widespread use of tampons carries a risk of tampon loss due to imperfect use. We performed a retrospective study including all women attending the emergency room (ER) with the complaint of tampon loss during 2011-2018. Overall, 72 women presented to the ER with a complaint of tampon loss. In 25% (18/72), a lost tampon was found on physical examination. The lost tampon was found in a higher rate among adolescents as compared to older women (4 (80%) vs. 14 (21%), 15.1, p = .01). Time from tampon loss to referral for evaluation was shorter among adolescents as compared to older women (7 ± 3 vs. 21 ± 21 h, p = .007). In most adolescents with a complaint of a lost tampon - it was eventually found on pelvic examination, as opposed to older women, in whom a finding was present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting due to tampon loss. The study protocol was approved by the Sheba Medical Center review board (March 15, 2018), 6345-19-SMC.IMPACT STATEMENTWhat is already known on this subject? Very little is known regarding the distinguished phenomena of tampon loss among adult females.What do the results of this study add? In most adolescents referred due to tampon loss - a tampon was found on pelvic examination, as opposed to older women.What are the implications of these findings for future clinical practice and/or further research? In most adolescents referred due to tampon loss - a tampon will be found on pelvic examination, as opposed to older women, in whom a finding is present in only one-fifth of cases. This highlights the importance of thorough examination of adolescents presenting with a loss of tampon.

Recurrent Urinary Tract Infection in Women: Primary Care Referral Patterns in a Tertiary Care Center.

OBJECTIVES: With more than 150 million urinary tract infections (UTIs) diagnosed globally per year, the impact on patient care is significant. We sought to examine appropriateness of management of recurrent UTI before referral to a female pelvic medicine and reconstructive surgery practice, as well as the characteristics of patients referred. METHODS: The medical records of 100 consecutive women with a diagnosis of "recurrent UTI" at a single institution between November 2010 and December 2015 were reviewed. The baseline clinical characteristics, laboratory testing, and treatments before and at referral to the female pelvic medicine and reconstructive surgery were examined by descriptive statistics. RESULTS: The evaluation and treatment patterns for recurrent UTI before specialist referral varied widely. Pelvic examination was performed in only 20.8% of patients before referral. Although most women had at least 1 culture performed (65.2%), treatments were variable. Only 42.7% of patients received recommended first-line antibiotic therapy. At symptom recurrence, only 47.2% of patients received a urine culture; most were empirically treated. Approximately 35.0% of patients received the same antibiotic upon their first recurrence. CONCLUSIONS: A large proportion of patients referred for recurrent UTI to a specialty practice had no prior culture, physical examination, or symptom-specific evaluation before referral. Despite existing guidelines, the evaluation, treatment, and referral patterns for recurrent UTI are highly varied and rarely conform to recommendations. Further studies are needed to confirm these trends and determine interventions to improve the efficacy and efficiency of primary care for women with recurrent UTI.

Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits.

Importance: Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits. Objective: To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type. Design, Setting, and Participants: This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020. Exposures: Visit paid by Medicaid vs other payment types. Main Outcomes and Measures: Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use. Results: A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02). Conclusions and Relevance: These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

Adolescents' right to confidential health care: knowledge, attitudes and practice of pediatricians and gynecologists in the primary healthcare sector in Belgrade, Serbia.

OBJECTIVES: Confidential counseling is a critical condition of the healthcare quality in adolescent medicine. This study aimed at assessing knowledge, attitudes and practice of primary healthcare pediatricians and gynecologists regarding adolescents' rights to confidentiality. METHODS: A cross-sectional study was conducted in a sample of 152 pediatricians and gynecologists who are employed at 13 primary healthcare centers in Belgrade, Serbia, in 2017-2018. Data were collected by a self-administered questionnaire purposefully constructed for this study. The questionnaire examined knowledge and attitudes toward adolescents' right to confidentiality as well as whether participating physicians practice confidential health care with adolescents. RESULTS: Physicians scored 4 out of 7 on a knowledge scale, but they overall supported adolescents' right to confidential health care (average attitude score was 71 out of 95). On average, physicians scored 21 out of 30 on practice of confidentiality scale. Multivariate analysis showed that better knowledge and stronger positive attitudes toward duty of confidentiality were associated with consistent practice of confidential health care. CONCLUSIONS: Knowledge about adolescents' rights to confidentiality and attitudes toward keeping adolescents' information confidential influence the practice of providing confidential services.

Surveillance patterns of cervical cancer patients treated with conization alone.

OBJECTIVES: To determine surveillance patterns of stage I cervical cancer after cervical conization. METHODS: A 25-question electronic survey was sent to members of the Society of Gynecologic Oncology. Provider demographics, surveillance during year 1, years 1-3, and >3 years after cervical conization, use of pelvic examination, cytology, Human papillomavirus testing, colposcopy, and endocervical curettage were queried. Data were analyzed. RESULTS: 239/1175 (20.1%) responses were collected over a 5-week study period. All providers identified as gynecologic oncologists. During year 1, 66.7% of providers perform pelvic examination and 37.1% perform cytology every 3 months. During years 1-3, 61.6% perform pelvic examination and 46% perform cytology every 6 months. At >3 years, 54.4% perform pelvic examination every 6 months and 43% perform annual pelvic examination. 66.7% of respondents perform cytology annually, and 51.9% perform annual Human papilloma virus testing. 85% of providers do not offer routine colposcopy and 60% do not offer endocervical curettage at any point during 5-year follow-up. 76.3% of respondents screen patients for Human papilloma virus vaccination. CONCLUSIONS: To date, there are no specific surveillance guidelines for patients with stage I cervical cancer treated with cervical conization. The most common surveillance practice reported is pelvic examination with or without cytology every 3 months in year 1 and every 6 months thereafter. However, wide variation exists in visit frequency, cytology, and Human papillomavirus testing, and there is a clear trend away from using colposcopy and endocervical curettage. These disparate surveillance practices indicate a need for well-defined, uniform surveillance guidelines.

Inequalities in the use of gynecological visits and preventive services for breast and cervical cancer in Roma women in Spain.

OBJECTIVES: The Roma population in Spain makes up about two percent of the population and has worse health indicators than the general population. We analyzed both populations in 2006 and 2014 to discover whether there are differences in terms of gynecological visits and preventive services for breast and cervical cancer in Spain. METHODS: Cross-sectional study is based on the Spanish National Health Survey (SNHS) of 2006 and 2012 and the National Health Survey of the Roma Population (NHSRP) of 2006 and 2014. RESULTS: Roma women used gynecological visits less than the general population in 2006 (ORa 0.5 [0.4; 0.6] and in 2014 (ORa 0.2 [0.2; 0.3)]. In addition, use of the mammogram was lower in Roma women (ORa 0.7 [0.6; 0.8]), especially in the ages of the screening tests, and they had lower probability of receiving cervical examinations in 2006 (ORa 0.5 [0.4; 0.6]) and in 2014 (ORa 0.7 [0.6; 0.9]). CONCLUSIONS: This study shows that the inequality gap in gynecological visits and preventive services for breast and cervical cancer in Roma women has persisted during the years studied (2006 and 2014), despite Spanish prevention policies.

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

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.

Experiences of women regarding vaginal examination during labor: A qualitative study.

The authors' aim in this study was to examine the experiences of women regarding vaginal examination (VE) performed during labor. This qualitative study is based on a hermeneutic-phenomenological approach. Fourteen women within the first 24 hours of the postpartum period following vaginal birth were enrolled in the study. We created six themes under the categories of "past experiences" and "future expectations". It was revealed that women had many negative feelings during the VE such as pain, ache, embarrassment, and fear. We recommend that the health care providers should inform women about relaxation methods that will reduce pain and discomfort.

Ultrasound feedback training increases trainee accuracy in vaginal assessment of fetal head position in labor.

OBJECTIVE: To evaluate the impact of an immediate ultrasound feedback intervention on trainee accuracy in vaginal-examination-based assessment of fetal head position. METHODS: This was a prospective cohort study conducted at a single tertiary care center. Six third-year and six fourth-year residents in an obstetrics and gynecology residency training program were the study subjects. The third-year residents underwent a training intervention in which they assessed fetal head position by transvaginal digital examination and then received immediate feedback through ultrasound demonstration of the actual position. All examinations were performed in women with a singleton gestation ≥ 35 weeks and cervical dilation ≥ 8 cm, following rupture of membranes. The comparison groups were third-year residents before, during and after training and fourth-year residents who were not exposed to the training intervention. The primary outcome was the difference in accuracy of fetal-head-position assessment on vaginal examination by third-year residents before and after ultrasound feedback training. Univariate and multivariate analyses were performed to identify factors associated with digital examination accuracy. RESULTS: Overall, 390 examinations were performed. The accuracy of fetal-head-position assessments of third-year residents was 55% (53/96) before training, 65% (74/114) during training and 70% (63/90) after training, while that of fourth-year residents who did not undergo training was 52% (47/90) (P = 0.04). Fourth-year residents who did not undergo ultrasound training demonstrated similar baseline accuracy to that of third-year residents pretraining (52% (47/90) vs 55% (53/96), P = 0.68), but had significantly lower accuracy than had the third-year residents post-training (52% (47/90) vs 70% (63/90); P = 0.01). Multivariable analysis revealed a positive association between ultrasound feedback training and the ability to assess accurately fetal head position. After adjusting for the variables included in the final model, examinations performed by third-year residents pretraining and those performed by fourth-year residents who did not undergo training were less likely to be accurate than those performed by third-year residents post-training (adjusted odds ratio, 0.48 (95% CI, 0.26-0.91) and 0.42 (95% CI, 0.22-0.80), respectively). CONCLUSION: Immediate ultrasound feedback training increased trainee accuracy in vaginal assessment of fetal head position in labor. Its integration into obstetric training programs should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Female Genital Mutilation/Cutting-Pediatric Physician Knowledge, Training, and General Practice Approach.

Female genital mutilation/cutting (FGM/C) is outlawed in much of the world but still mainly occurs from infancy-age 15. Many at-risk and FGM/C-affected girls live in the US. No standard pediatric training exists. A questionnaire assessing FGM/C education, knowledge, diagnostic confidence and external genital examination (EGE) approach was sent to pediatric listservs at 3 hospitals and a child abuse pediatrician (CAP) network. Analysis used χ2 and Fisher's exact tests. Compared to general pediatricians, CAP reported more FGM/C education (RR 2.0 [95% CI 1.3-3.2]), awareness of ICD-9/10 codes (RR 3.2 [95% CI 1.4-7.3]), confidence in identifying sub-types (RR 4.5 [95% CI 2.3-8.7]) and discussing FGM/C (RR 4.2 [95% CI 2.3-7.6]). For 6-12 month olds, 10% of general pediatricians reported never performing EGE at female well child visits (WCV), increasing to > 50% for 17-18 year olds. Pediatric physicians are not trained to diagnose or manage FGM/C. EGE are not done at WCVs and FGM/C diagnoses are missed.

Potential excess of vaginal examinations during the management of labor: frequency and associated factors in 13 Peruvian hospitals.

BACKGROUND: A high number of vaginal examinations (VEs) may lead to a higher risk of infections, as well as discomfort/dissatisfaction with intrapartum care. OBJECTIVE: To determine the frequency of potential excess of vaginal examinations (PEVE) during the management of labor and identify its associated factors, in Peruvian hospitals. METHODS: Secondary analysis of the data collected in the DisrespEct and abuse during ChIlDbirth in pEru (DECIDE) study, held between April and May 2016. In this study, women hospitalized in Peruvian hospitals right after giving birth were surveyed by trained personnel. PEVE, the main outcome, was considered as five or more vaginal examinations (VEs) performed during the management of labor. Poisson regression models with robust variance were performed to calculate crude and adjusted prevalence ratios (cPR and aPR) as well as their 95% confidence intervals (95% CI). RESULTS: One thousand four hundred twenty registries of 13 hospitals from 8 Peruvian cities were evaluated. The number of women studied at each hospital ranged between 100 and 129. The median age was 26 years (interquartile rank: 22-31). The median number of VEs was 3 (interquartile rank: 2-5). The proportion of women who underwent PEVE was 33.9%, this ranged from 0.9 to 69.9% at the studied hospitals. The frequency of PEVE was higher in women who attended > 2 obstetric psychoprophylaxis sessions, compared to those who attended ≤ 2 sessions (aPR: 1.78 95% CI: 1.01-3.12); and among women who gave birth between 18:00 h and 23:59 h, compared to those who did it between 7:00 and 17:59 h (aPR: 1.28 95% CI: 1.04-1.57). CONCLUSION: Around one in three women underwent a PEVE, although this frequency varied widely across the evaluated hospitals. Women with more psychoprophylaxis sessions, and who gave birth between 18:00 h and 23:59 h, had a higher PEVE frequency. Future studies should assess in depth the causes and consequences of this high frequency.

Receipt of Pelvic Examinations Among Women Aged 15-44 in the United States, 1988-2017.

Pelvic examination has been commonly performed as part of a physical examination for women in the United States. However, the value of routine pelvic examinations has been questioned recently (1,2). In 2012, the American College of Obstetricians and Gynecologists (ACOG) recommended annual pelvic examinations for women aged 21 and over as part of the well-woman visit (3). In 2018, ACOG advised that pelvic examinations be performed when indicated by medical history or symptoms (4). Using National Survey of Family Growth (NSFG) data through 2017 for women aged 15-44, this report describes trends overall and by age since 1988 in the receipt of pelvic examinations in the past year, and differences by Hispanic origin and race, education, poverty status, and health insurance status for 2015-2017.

Combination of noninvasive methods in diagnosis of infertile women with minimal or mild endometriosis, a retrospective study in China.

This study means to investigate a combination of noninvasive methods in diagnosis of minimal or mild endometriosis expecting to narrow down the range of laparoscopic exploration for female infertility.It is a retrospective case control study of totally 447 patients suspected unexplained infertility before surgery were eligible from May 2012 to February 2017. Of these, 299 patients were laparoscopy-proved minimal or mild endometriosis group, the remaining 148 patients served as control group (normal pelvis). Preoperative age, duration of infertility, type of infertility, body mass index, baseline follicle-stimulating hormone, anti-Müllerian hormone, serum CA125, clinical symptoms, findings on vagino-recto-abdominal examinations and pregnancy prognosis had been recorded. Every variable and their combinations were evaluated.Any single factor had limited diagnostic value. The cut-off value for CA125 was 19.25 IU/L. Parallel testing had a higher sensitivity at 81.3%. Serial tests of vagino-recto-abdominal examination combined with dysmenorrhea or positive CA125 got reasonable sensitivity (51.4% and 49%), remarkable high specificities (95.7% and100%) and Positive Predictive Value (96.4% and 100%). Multivariate logistic regression identified the following factors in decreasing order of importance: (1) vagino-recto-abdominal examinations, (2) CA125, (3) dysmenorrhea, their ORs being 16.148, 3.796, and 2.809, respectively. The spontaneous pregnancy rate (50.8%) in minimal or mild endometriosis was higher than control (35.6%, P = .043).A combination of noninvasive diagnostic methods had certain preoperative diagnostic value of minimal or mild endometriosis, which might benefit some patients from avoiding laparoscopic surgery.

Assessment of labor progression by intrapartum ultrasonography among term nulliparous women.

OBJECTIVE: To assess cervical dilation, fetal head station, and fetal head position by intrapartum ultrasonography and to compare the approach with digital vaginal examination (DVE). METHODS: An observational study conducted from October 2015 to January 2017 among term nulliparous women in active labor at a tertiary hospital in Delhi, India. Cervical dilation, head station, and head position were assessed by DVE, followed by ultrasonography within 10 minutes. The women's preference was also evaluated. RESULTS: Overall, 458 observations were obtained for 215 women. Cervical dilation measured by DVE was strongly correlated with ultrasonography findings (intraclass correlation coefficient, 0.945; 95% confidence interval, 0.932-0.956; κ=0.837; P<0.001). Data for fetal head station and head position showed a fair correlation (κ=0.353 and κ=0.554, respectively; both P<0.001). The majority of women (186/215, 87%) reported a preference for ultrasonography over DVE for assessment of labor progression in a future pregnancy. CONCLUSION: Intrapartum ultrasonography was preferred as an objective assessment tool for labor progression among term nulliparous women and therefore should be practiced in all labor rooms. Further studies on interobserver variation are recommended to establish the reproducibility of intrapartum assessment by ultrasonography.

Shared Decision-Making Framework for Pelvic Examinations in Asymptomatic, Nonpregnant Patients.

Controversy exists regarding whether to perform pelvic examinations for asymptomatic, nonpregnant patients. However, several professional organizations support the notion that health care providers should no longer recommend that asymptomatic patients receive a yearly pelvic examination. At minimum, health care providers must respect patients' autonomy in decision making around this examination and initiate a joint discussion about whether to proceed with a pelvic examination. Shared decision making is a model used in other aspects of medicine that can aid such discussions. This model recognizes two experts in these clinical encounters-the health care provider is the expert regarding medical information and the patient is the expert regarding their values, preferences, and lived experiences. When shared decision making is used, not only is each expert valued for their knowledge, but the power differential shifts to a shared power model. This commentary aims to educate about shared decision making, explain why shared decision making is appropriate to use when discussing whether to perform a pelvic examination, and provide a framework for using shared decision making in discussing whether to proceed with a pelvic examination with asymptomatic, nonpregnant patients.

Barriers to implementation of a pelvic examination among family doctors in primary care clinics.

OBJECTIVE: although the pelvic examination of female patients should be an integral part of the physical examination in family medicine there are many barriers to the conduct of this intimate examination by family doctors. THE OBJECTIVE: an assessment of the attitudes and barriers reported by family doctors on conducting a pelvic examination. METHODS: An anonymous, self-administered questionnaire. RESULTS: Two hundred thirty doctors participated in the study, of who 157 were males (68.9%). The mean age was 42.2 ± 9.6 years. 179 family doctors (77.8%) thought that the pelvic examination should be an important part of their work as a family doctor, 100 (43.9%) said that they had conducted a pelvic examination in the past, but the majority (85.2%) had not done a pelvic examination over the previous year. Senior doctors did more pelvic examinations than younger doctors (P = 0.007). Graduates of Israeli medical schools were more likely than those who graduated elsewhere to state that family doctors should do pelvic examinations (P = 0.032). Graduates of non-Israeli medical schools cited less experience (P = 0.002) and less motivation (P = 0.006) as reasons for not doing pelvic examinations. CONCLUSIONS: Although most family doctors believe that pelvic examinations are an important part of their work, only a small percentage actually do a pelvic examination. Among the reasons for not doing the examination are lack of knowledge, lack of experience, and work burden.

Women's experiences with vaginal examinations during labor in the Netherlands.

INTRODUCTION: Vaginal digital examination (VE) is a routine medical procedure during labor to assess the start and progression of labor. This study explores women's experiences with VE's during labor in the Netherlands. METHODS: An exploratory anonymous online survey was distributed among Dutch women who underwent a trial of labor and gave birth to a living term child in the previous six months. Unadjusted odds ratios are calculated to establish associations between women's characteristics and reporting a negative experience with VE's. RESULTS: Of the 159 women who met the inclusion criteria, 56 women (35.2%) reported a negative experience with the VE. These women reported more pain, embarrassment, not being able to relax, not feeling respected and not feeling the possibility to stop the examination. The odds of reporting negative experiences increased by giving birth in hospital, an instrumental delivery, more examinations, more different caretakers performing the examination and caregivers not introducing themselves before the examination. About 41.7% of the women reported being examined more often than advised in national and international guidelines (every two to four hours). DISCUSSION: Although our study is limited, it shows that experiences with the VE during labor can be negative and should be considered carefully. We promote research of and teaching the use of additional noninvasive methods to assess progression of labor in daily clinical practice. We conclude that the number of VE's during labor should be restricted as much as possible. VE's should only be performed in the interest of the woman in labor, after her informed consent and preferably performed by as few different caregivers as possible.

Extent, regional variation and impact of gynecologist payment models in routine pelvic examinations: a nationwide cross-sectional study.

BACKGROUND: Based on moderate quality evidence, routine pelvic examination is strongly recommended against in asymptomatic women. The aims of this study was to quantify the extent of routine pelvic examinations within specialized health care in Norway, to assess if the use of these services differs across hospital referral regions and to assess if the use of colposcopy and ultrasound differs with gynecologists' payment models. METHODS: Nationwide cross-sectional study including all women aged 18 years and older in Norway in the years 2014-16 (2,038,747). Data was extracted from the Norwegian Patient Registry and Statistics Norway. The main outcome measures were 1. The number of appointments per 1000 women with a primary diagnosis of "Encounter for gynecological examination without complaint, suspected or reported diagnosis." 2. The age-standardized number of these appointments per 1000 women in the 21 different hospital referral regions of Norway. 3. The use of colposcopy and ultrasound in routine pelvic examinations, provided by gynecologists with fixed salaries and gynecologists paid by a fee-for-service model. RESULTS: Annually 22.2 out of every 1000 women in Norway had a routine pelvic examination, with variation across regions from 6.6 to 43.9 per 1000. Gynecologists with fixed salaries performed colposcopy in 1.6% and ultrasound in 74.5% of appointments. Corresponding numbers for fee-for-service gynecologists were 49.2% and 96.2%, respectively. CONCLUSIONS: Routine pelvic examinations are widely performed in Norway. The variation across regions is extensive. Our results strongly indicate that fee-for-service payments for gynecologists skyrocket the use of colposcopy and increase the use of ultrasound in pelvic examinations of asymptomatic women.

Medical students' experience of performing female pelvic examinations: Opportunities and barriers.

BACKGROUND: Teaching and learning female pelvic examination within the undergraduate medical curriculum offers some potential challenges. One such is the extent to which students are provided practice opportunities with patients in the clinical setting. AIMS: To quantify how many pelvic examinations, on real patients, have been performed by medical students at the point of graduation, and to explore opportunities and barriers to performing these examinations. MATERIALS AND METHODS: A retrospective study using a self-completed, anonymous, electronic survey was developed as part of a multi-centre study. Data were collected in the immediate period after graduation from the medical programs at the University of Auckland and Flinders University in 2013. An ordinal set of range categories was used for recording numbers of examinations. RESULTS: The combined response rate for the survey was 42.9% (134/312). The median range category for the number of pelvic examinations performed in patients who were not in labour was 6-9 and in labour was 2-3. Thirty-three percent of medical students had never performed a pelvic examination in labour. Male medical students performed significantly fewer pelvic examinations compared with female students. Self-reported barriers to performing the pelvic exam include: gender of the student, 'gate-keeping' by other health professionals, lack of confidence and patient factors. CONCLUSIONS: The majority of medical students have performed several pelvic examinations on real patients at graduation. Male gender and access being limited by midwives were the main barriers to performing female pelvic examinations. Medical curricula need to address these issues in the learning environment.