Out Patient Hysteroscopy Unit GUIDELINES

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Hester Thomas
5 years ago
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1 Out Patient Hysteroscopy Unit GUIDELINES 1

2 AIMS The aim of the menstrual assessment clinic [MAC] (incorporating outpatient hysteroscopy) at Queen Charlotte s and Chelsea Hospital will be to provide a one-stop diagnostic and treatment clinic for non-pregnant women presenting with abnormal vaginal bleeding bleeding. The clinic will facilitate the management of abnormal vaginal bleeding by optimally utilising medical and nursing resources with seamless access to ultrasound scanning and hysteroscopy. Treatment will be more patient orientated with much reduced waiting time and improved communication with both patients and General Practitioners. The improved outpatient diagnostic and therapeutic facilities will reduce the need for day case and inpatient theatre admission

3 STRICT REFERRAL CRITERIA Pre/perimenopausal bleeding Persistent menorrhagia (not responding to AT LEAST 3 months of medical therapies such as antifibrinolytics (Tranexamic acid 1g tds) and non steroidal anti inflammatories (Mefanamic acid 500mg tds) Intermenstrual bleeding Persistent breakthrough bleeding (on combined oral contraceptive, progestogen only pill, Implanon or Depo Provera) Post/perimenopausal bleeding in HRT users Persistent (>3 months) breakthrough bleeding on sequential HRT Persistent bleeding (>6 months) on initiation of continuous combined HRT New bleeding on continuous combined HRT after >/= 1 year of amenorrhoea INAPPROPRIATE REFERRALS Include Post coital bleeding should be referred to colposcopy clinic Post menopausal bleeding (not on HRT) should be seen in rapid access clinic first and referred on if appropriate Complications of early pregnancy Menorrhagia where medical therapy has not been attempted Breakthrough bleeding on HRT / contraceptives where manipulation of dosage or regimen has not been attempted first. Early appointment service for other gynaecological problems 3

4 REFERRALS Referrals will be accepted from: 1) Consultant lead clinics at Queen Charlottes & Hammersmith 2) General Practitioners The clinic will initially see patients who have been assessed in gynaecology outpatients by consultants and referred on for further assessment. Ultimately it is expected that referring general practitioners will be able to write to the MAC women s outpatients at Queen Charlotte s and Chelsea Hospital. Referral letters will be studied by Mr Panay and inappropriate referrals will be diverted to the outpatient gynaecology clinic. Appropriately referred patients will be sent an appointment for the MAC which will take place on a Thursday mornings and will run in parallel to the rapid access clinic. NB. The clinic is one of the pilot sites for the EHH book and go initiative which in the future, will allow direct electronic booking for General Practitioners via NHS net. It is anticipated that a maximum of six patients will be seen in the clinic. These patients will be booked from to by the gynaecology outpatient booking clerk allowing 30 minutes per patient. 4

5 STAFFING Consultant The MAC will be staffed by Mr Nicholas Panay who will be lead clinician for the service. Nursing Nursing support will be provided by GOPD. Clerical Support Receptionist and secretarial support will be provided by staff from the preexisting rapid access clinic. Ultrasound Scanning Scanning will ultimately be carried out in the clinic by Mr Nicholas Panay when an ultrasound scanning machine becomes available. In the meantime, six ultrasound slots have been created by Mrs Jean Hollingsworth (Ultrasound Service Manager) to allow efficient scanning of patients in the ultrasound department adjacent to the clinic. It is hoped that the ultrasonographer dedicated to the clinic will also conduct a relevant MSc research project in all consenting patients. Other staff SHO s, SpR s, medical students and nursing students/staff will be encouraged to attend for training purposes but will be supernumerary to the running of the service. 5

6 VISIT DETAILS Assessment 1. A standardised history will be taken on a proforma (appendix 1) which will subsequently allow ease of entry of information onto a computer database. 2. Transvaginal scanning will initially be performed by a dedicated ultrasonographer but ultimately by Mr N Panay when a scanning machine becomes available for use within the clinic. 3.Pelvic examination will then be carried out and a smear test taken if appropriate data entry will again be carried out on the proforma 4.If endometrial thickness is >/=4mm on TV USS patients will undergo hysteroscopy. In menstruating women or women on HRT or the combined pill, scans will be timed to the post-menstrual phase. In women with postmenopausal bleeding malignancy can be virtually excluded if sonographic endometrial thickness is < or = 4.0mm. 3 Diagnostic hysteroscopy with directed biopsies will be carried out, proceeding to therapeutic hysteroscopy with the same hysteroscope if a polyp or small fibroid is seen. Operative findings will also be entered on the proforma. All information will be ultimately be transferred to a database and used for audit and research. NB: Premedication with mefanamic acid 500mg will be given 1 hour prior to the procedure to minimise post operative discomfort 4 and lignocaine spray will be applied to the cervix pre hysteroscopy to minimise cervical discomfort. 5 FURTHER MANAGEMENT / FOLLOW UP (see algorithm) 6

7 This will depend upon results of the investigations performed. Possible outcomes are: -Reassurance and discharge back to GP -Standardised outpatient treatment -Inpatient investigation / treatment -FU by Gynae Oncology team e.g. for colposcopy or EUA/laparotomy -Gynae OPD follow up for results / further management if necessary -If OP hysteroscopy is not possible a pipelle may be attempted with FU in GOPD and/or the patient will be referred for hysteroscopy under general anaesthesia as a day case or inpatient. 7

8 KEY RECENT REFERENCES 1) Tahir MM, Bigrigg MA, Browning JJ, Brookes ST and Smith PA. A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. Br J Obstet Gynaecol 1999; 106(12): ) Kremer C, Duffy S, Morony M. Patient satisfaction with outpatient hysteroscopy versus day case hysteroscopy: randomised controlled trial. Br Med J 2000; 320: ) Bakour S.H., Dwarakanath L.S., Khan K.S., Newton J.R., Gupta J.K. The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplasia and cancer in postmenopausal bleeding. Acta Obstet Scand 1999; 78(5): ) Nagele F., Lockwood G., Magos A.L. Randomised placebo controlled trial of mefanamic acid for premedication at outpatient hysteroscopy: a pilot study. Br J Obstet Gynaecol 1997; 104(7): ) Davies A., Richardson R.E., O Connor H., Baskett T.F., Nagele F., Magos A.L. Lignocaine aerosol spray in outpatient hysteroscopy: a randomised double-blind placebo controlled trial. Fertil Steril 1997; 67(6):

9 Menstrual Assessment Clinic ALGORITH GP Referral Letter Consultant Referral 1)Back to GP 2)Routine GOPD 3)Gynae Onc Clinician review Appointment (see within 2-4 weeks) History / Examination +/- Smear Transvaginal USS Endo</=4mm GP / GOPD If Endo>4mm Not possible Pipelle/GA Diagnostic +/-Therapeutic hysteroscopy +/- Biopsy hysteroscopy?malignancy No pathology/pathology Rx. e.g small polyp/fibroid Gynae Onc FU GP or GOPD FU 9

Abnormal uterine bleeding:

Primary Care Women s Health Forum 16th June 2010 Abnormal uterine bleeding: The University Of Birmingham T Justin Clark MD (Hons), MRCOG Consultant Obstetrician and Gynaecologist Birmingham Women s Hospital