Why Do I Need a Pap Smear to Get Birth Control Pills?

Birth Control Clinic
A woman in a family planning clinic in Mexico City holds birth control pills, while sitting by a display of various contraceptive devices. A doctor writes out her perscription. (Photo by Tom Nebbia/CORBIS/Corbis via Getty Images). Tom Nebbia/CORBIS/Corbis via Getty Images

Question: Why Do I Need a Pap Smear to Get Birth Control Pills?

Many doctors require you go get a Pap smear in order to get a prescription for birth control pills. I used to believe that there was a good reason for this. I was wrong. Forcing women to get Pap smears to access contraception is paternalism at its worse. There is no good medical reason to require a Pap smear for contraception access. What there is, is expediency. The need for birth control helps get women into the stirrups to be screened for cervical cancer. However, education is a better tactic than coercion. No woman should think the Pap smear is required by law, and yet that is one of the most frequent search terms that brings people to this site.  

Answer:  Technically speaking, you don't.. 

The Pap smear is a test used to detect cellular changes. These changes, if ignored over many years, could lead to cervical cancer. Cervical cancer was once one of the leading causes of death among women. However, thanks to regular Pap smears, that's no longer true. The death rate due to cervical cancer has declined more than 50% in the United States since the 1970s. That's why doctors sometimes require women to get Pap smears in order to obtain birth control pills. It's not medically necessary. It IS an extremely effective way to encourage women to get regular Pap smears. After all, sexually active women often want oral contraceptive pills. They don't necessarily want a Pap smear. 

Very few women actually enjoy going to the gynecologist. As with any sort of preventive care, many women would choose to avoid going in for a pelvic exam if they didn't need to see the doctor. Often, the main reason to go in to the gynecologist is for pregnancy care or to access their chosen method of birth control. If they didn't need those things, they might also not get screened for cervical cancer, STDs, or other women's health conditions. 

In fact, scientists have long thought that this is one of the reasons that cervical cancer deaths remain more common in older women. It's not just the latency period from initial HPV infection to cancer development. It is that these are women who don't need birth control pills and therefore may be less proactive about seeking out preventive care. They don't get regular Pap smears because they have a low perceived risk of sexually transmitted diseases, and they don't need birth control pills or pregnancy care. Therefore, without early detection, any cancer they develop is more likely to prove fatal. Lesbians may also be at high risk for cervical cancer death. Like older women, they tend to be screened less often than they should be -- for similar reasons. Women who are only having sex with other women do not have worries about unintended pregnancy. They may have a (incorrect) feeling that they are not at risk for STDs. They may also be afraid of experiencing discrimination if they are open about their sexual oriention with their doctors. 

In online forums, I often see questions along the lines of "Why do I have to get a Pap smear in order to get birth control pills? I don't want a doctor poking around in my business. Only my partner should look at me down there." Questions like this clearly show why some doctors feel it is necessary to have the requirement. Many women find Pap smears embarrassing. They would avoid getting them if they could do that and still get the other gynecological care they need. Unfortunately regular screening is essential for early detection of cervical cancer. That's something for which every single sexually active woman, no matter how few people she is having sex with, is at risk. Is it paternalistic to require a Pap smear in order to get contraceptive pills? Yes. Sadly, it's also effective. 

That doesn't mean it's right. Women have the right to make an informed choice about their health risks. That includes making a decision to avoid screening tests. No woman should be denied contraception because she doesn't want to be screened for cervical cancer. That's true whether or not her doctor believes that decision is in her best interest. 

Note: Sometimes a teenager goes to a doctor for birth control pills before she becomes sexually active, perhaps to regulate her period. In such cases, the doctor may prescribe the pills without a pelvic exam. However, once a person is sexually active, the pelvic exam and Pap smear are more likely to be required. They should not be required annually. However, they may be required at regular intervals. 

My Evolving Perpective

When I initially wrote this article, I thought requiring Pap smears to get birth control pills was a good thing. I knew it was paternalistic. However, I thought it did more good than harm. Since then, I've read many women's stories of their experiences getting Pap smears. It changed my mind. I'm no longer in favor of using birth control pills as a way to encourage Pap screening. I still think that regular, although not yearly, screening is important. However, I think that it would be better to recruit women through education than through mechanisms that are perceived as highly coercive. Your stories have changed my mind. Thank you.

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