Mr Doug Barclay Gynaecologist Ascot Central Women s Clinic Auckland. Mr Simon Edmonds Gynaecologist Middlemore Hospital Auckland

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Godfrey Eaton
6 years ago
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#69: Practical Mirena Insertion and Pipelle Endometrial Sampling

1 Mr Doug Barclay Gynaecologist Ascot Central Women s Clinic Auckland Mr Simon Edmonds Gynaecologist Middlemore Hospital Auckland 16:30-17:25 WS #69: Practical Mirena Insertion and Pipelle Endometrial Sampling 17:35-18:30 WS #79: Practical Mirena Insertion and Pipelle Endometrial Sampling (Repeated)

2 Practical Mirena Insertion and Pipelle Endometrial Sampling Simon Edmonds Douglas Barclay Orna McGinn

3 Why are we doing this session? Give you a taste.. Improve your skills Improve the patient journey Feedback

4 Plan for this session 20 minutes on background and pathway for AUB Case Histories Videos of pipelle and mirena insertion Discussion and feedback Training on models

5 Why in Primary Care? 1 in 16 women age years consults her G.P with AUB. each year Pre-menopausal women having hysterectomies in NZ 80% (3500) for menorrhagia 1990s approx 65% or less in 2000s Risk of hysterectomy under the age of 50 NZ 20% UK 17% USA 40% Denmark 10%

6 What is menorrhagia? Subjective Excessive blood loss at time of menstruation flooding heavy clots Objective > 80mls volume loss per menses Low Hb Low ferritin Does not matter, unless symptomatic Cultural Racial Religious Personal

7 Diagnosis of exclusion Dysfunctional uterine bleeding, acute PID Fibroids outside cavity or submucous Polyps Endometrial hyperplasia.. Endometrial cancer.. Cervical cancer Clotting abnormalities etc

8 Why is it an issue now? Commonest cause of iron deficiency anaemia in women of reproductive age Significantly affects QoL scores ltd to house socially embarassing inability to work expensive.even if normal Hb

CMDHB Grading Between 100-150 GP referrals per week

9 CMDHB Grading Between GP referrals per week (now e-referrals) 15-20% colposcopy Of the remaining: 22% are for Menorrhagia approx. 800 per year Virtual letters fertility/pcos/insufficient info/ Mx plans

10 Who should Manage it? At least 70% of case are due to DUB dysfunctional uterine bleeding just the hormones hormone imbalance NO true pathology that requires surgery.. So why not manage in primary care?

11 Secondary/Tertiary Care

12 Interface Providing the tools to assist primary care in: diagnosis referral for further tests recommended treatment pathways referral for specific surgical treatment

13 Tools and resources Appropriate training -guidelines -practical training in pipelle/mirena Appropriate access to tests -ultrasound Appropriate renumeration/time

14 What can Primary Care do? Medical Management tranexamic/mefenamic acid provera/net D5-25 POP/COCP/Depo P/Jadelle Why not the next stage mirena coil insertion?

15 Who do you investigate further and how? Ultrasound scanning.. Endometrial pipelle sampling..

16 ET Polyps Fibroids

17 Why is BMI an issue? Women >90kg or BMI>35, ET>12mm - up to 40% have Endometrial Hyperplasia ET<12mm - less than 1% have Endometrial hyperplasia Obesity is the biggest risk factor

18 What can secondary care do? Attempt to set out a Pathway: Facilitate pipelle endometrial sampling by GPs (41) Provide a training package and credentialling document Have clear guidelines and flow charts for patient selection Create funding models for education and pipelle sampling

19 **BMI **Age

20 Has it worked? Slowly..!! 90 patients in 18 months on pathway?10-14 complete Why not? Access to funding/remuneration Mismatch in payment Lack of a GP champion Dissemination of project

21 Changes being made Project now taken over by new clinical lead in gynaecology at CMH last 12 months GP liason Womens Health by CMH Access to repayment through POAC (Orna) Formal training package for mirena insertion? Funding of mirena by CMH Or?? GPwSI in each PHO Or?? National RNZCGP or RANZCOG training programme (limited availability for training through local sexual health clinics). Payment too. Feedback please

22 Case Histories (1) 29 year old woman, Para3 heavy periods 5 months, no IMB Hb 102 clinical examination normal, normal BMI 3 months of cyclical progesterone, tranexamic acid, iron No improvement, Hb now 92 Mirena insertion settled by 6 months, Hb 121

23 Case Histories (2) 37 year old woman, nulliparous heavy prolonged periods 12 months, no IMB Hb 128 clinical examination normal, BTB on COCP despite biphasic /triphasic preparations BMI 37 TV U/S ET 10mm and pipelle normal sample Mirena insertion settled by 6 months

24 Case Histories(3) 39 year old woman, nullip, BMI 39 irregular periods 5 months, Hb 112 clinical examination normal 3 months of cyclical progesterone, tranexamic acid, iron vs TV U/S ET 19mm. Pipelle sample: endometrial hyperplasia OPD Hysteroscopy Directed Bx simple Mirena coil Mirena insertion settled by 6 months

25 Case Histories(4) 27 year old woman, Para 1 heavy periods 5 years, BMI 61 Hb 79 clinical examination normal TV U/S ET 17mm Pipelle at least complex hyperplasia GA Hysteroscopy frond like lesion at fundus Histo: Endometrial CA. MRI stage 1b TAH + BSO pelvic nodes +ve Stage upgraded

26 Pipelle Sampling:

27 Top tips: Make sure not pregnant -?urine hcg No cleaning of the cervix required No sound needed Single tooth tenaculum Don t pull catheter all the way out..

28 Mirena insertion:

29 Conclusions Consider upskilling in mirena insertion / pipelle sampling Local DHBs may be interested in setting up clinical pathways More work needs to be done: access to funding?gpwsi availability of mirenas non funded governance and continued education

Menorrhagia Update. Simon Edmonds Middlemore Hospital Ascot Central Women s Clinic Auckland

Menorrhagia Update. Simon Edmonds Middlemore Hospital Ascot Central Women s Clinic Auckland Menorrhagia Update Simon Edmonds Middlemore Hospital Ascot Central Women s Clinic Auckland What is it? Subjective Excessive blood loss at time of menstruation flooding heavy clots Objective > 80mls volume