question and answer
August 1994
PAUL F. MURPHY, MD, of Sydney, N.S., writes in with this problem: "If a teenager comes to you and requests the birth control pill and, after diligent and comprehensive counselling, refuses to have a Pap smear, do you give her the pill because she says that's what she came for, not a Pap smear and a lecture! and because it may be more ethical to help prevent an unwanted pregnancy than worry at this stage about cancer? Or, do you refuse to give her the pill and risk her alienation and an unwanted pregnancy because you feel you are being negligent in giving it to her without doing a Pap?"
There are two parts to this question: the medical issue and the ethical one. As usual, they are interrelated. Medical rules of practice recommend that if a woman is sexually active and on the oral contraceptive we need to take a history, measure the blood pressure, perform (and teach) a breast exam and perform a pelvic examination with a Pap smear. This is required yearly. More frequent visits may be required for counselling only, and more frequent visits are required for compliance in adolescents. This is important to teach preventative medecine (breast exams, sexually transmitted disease, importance of yearly Pap tests, etc.) (A Clinical Guide to Contraception. Speroff 1992). Regarding this particular patient, my own opinion is that my office is not a drug dispensary. Until OCs become an "over the counter drug" (and maybe it should be) I follow the rules of practice and do not just hand out prescriptions of anything. In my adolescent gynecology clinic I find that some adolescent patients require a female physician before they accept a pelvic exam. TF
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