Postmenopausal bleeding (PMB) guidelines for women with abnormal vaginal bleeding

Transcription

1 Guideline Postmenopausal bleeding (PMB) guidelines for women with abnormal vaginal bleeding 1 Scope For local use. 2 Purpose To provide evidence based care relating to several areas of the service including staffing, clinic environment and clinical practice. 3 Introduction The postmenopausal bleeding (PMB) clinics are specialised clinics for the investigation of women who have abnormal vaginal bleeding on/ after the menopause. In the context of the service outpatient hysteroscopy is utilised as a diagnostic tool, usually for women who have had an abnormal pelvic ultrasound scan. The PMB service within the Trust is multidisciplinary with trained medical and nursing personnel offering diagnostic services and therapeutic interventions. Only trained staff offer these services in the unsupervised capacity. As a training centre, untrained staff will only offer these services when supervised by an appropriately trained member of the team. All nurse practitioners undertaking hysteroscopy must be accredited; those learning must only do so under supervision of an accredited hysteroscopist. Close liaison exists between the radiology and histopathology services and other agencies ie primary care. 4 Referral to the PMB service New referrals come from several sources: general practitioner other hospital consultants (from this trust and others) other gynaecology clinics/ wards clinical genetics Cambridge University Hospitals NHS Foundation Trust Page 1 of 10

2 The usual method of referral is via the e-referral service using the cancer two-week-wait referral proforma. To assist appropriate clinic scheduling, referrals are channelled through the gynaecological oncology team to ensure appropriate utilisation of available clinics in conjunction with the gynaecological oncology administration team. The general practitioner can book an appointment directly for a patient using the choose and book system. These referrals also require triage (see triage of gynaecological oncology fast-track referrals). 4.1 Patients who have not had a scan An appointment is made for a diagnostic pelvic ultrasound scan within two weeks of referral. 4.2 Patients who have had a scan If the GP practice has already arranged an ultrasound scan a date is given for either consultation or outpatient hysteroscopy. Occasionally an appointment is not necessary. 4.3 Patients with clinically suspicious cervix An appointment is made for an urgent colposcopy appointment. An ultrasound scan may also be arranged. 5 Appointments Once an appointment has been negotiated a confirmation letter of appointment and patient information leaflet (investigation of women with abnormal vaginal bleeding around/ after the menopause- patient information leaflet) is sent to the patient. 6 Ultrasound scan results Pelvic ultrasound is performed in the ultrasound department, level 3, Addenbrooke s Hospital. 6.1 Management If the scan shows the endometrial thickness is less than 5mm with no abnormal pathology seen and the GP has commented on the referral that the patient has a normal lower genital tract examination then the woman is reassured and discharged back to the care of their GP. The ultrasound department will inform the gynaecology administration staff of the outcome and send a letter to the GP. Cambridge University Hospitals NHS Foundation Trust Page 2 of 10

3 If the scan shows the endometrial thickness to be less than 5mm but where pathology is seen, the woman is referred to the PMB clinic for consultation and management. This usually occurs on the same day. If the scan is the same as or more than 5mm the woman is referred to the PMB clinic for consultation and management. This usually occurs on the same day. If the scan shows ovarian pathology (irrespective of endometrial thickness) the woman is referred to either the PMB or gynaecological oncology clinic. This usually occurs on the same day. For women requiring an outpatient hysteroscopy this is usually offered to the woman on the same day. If inconvenient or if there are medical reasons why this should not happen then an appointment is made for a later date (within target). 7 Clinic schedule Hysteroscopy should be performed in scheduled hysteroscopy clinics that are properly equipped, staffed and set up to ensure the smooth running of the procedure. The number of patients to be seen in a clinic is totally dependant on the type of clinic. 7.1 Clinic staff The PMB team comprises: Hysteroscopy nurse practitioners Gynaecological oncologists Surgical nurse practitioner Specialist registrars Gynaecological oncology administration team Unless specifically requested by the referring agency all patients will be allocated the next available appointment (utilising all the available clinic slots). This we have termed generic referral. In this way a more even distribution of resources is achieved and waiting times for appointments will meet the cancer pathway targets. 7.2 Clinic types PMB one-stop clinic (scan and procedure on same day) Hysteroscopy clinic (usually where the scan has been performed prior to referral by GP) Therapeutic clinic - Use of Versapoint or Myosure Cambridge University Hospitals NHS Foundation Trust Page 3 of 10

4 8 Diagnostic hysteroscopy The clinic is held in the colposcopy suite, clinic 21. All patients have a consultation prior to the procedure with verbal consent documented within EPIC. The clinic is staffed by a trained nurse and a healthcare assistant (HCA). An electronically operated gynae couch with adjustable leg rests is used. This may be raised, lowered and tipped as necessary. The leg rests may be removed and the couch used flat when required. The couch will take weight up to 170kg. There is a bariatric couch available in the colposcopy suite examination room for women over 170kg and up to 240kg. There is a TV monitor available for patients to view the procedure if they wish. The monitor is used by the practitioner. 8.1 Procedure A speculum may be inserted into the vagina and the cervix visualised and cleaned with antiseptic solution. Cervical cytology (smears)/ swabs are taken if indicated, prior to the application of antiseptic wash. Occasionally vaginoscopy is performed. A 3.1mm flexible hysteroscope is inserted into the cervical os and into the uterine cavity. When required there is equipment and local anaesthesia if necessary to dilate the cervical os. Routine administration of intracervical or paracervical local anaesthetic is not indicated. The uterine cavity is distended with sterile saline. Following inspection of the cavity with recognition of landmarks (tubal ostia) an endometrial sample is taken and sent for histological diagnosis. On occasions polyps or other pathology may be seen and these may be suitable for removal either immediately or in a subsequent clinic using the Versapoint or Myosure equipment. On occasion it may be necessary to fit a Mirena IUS (Levenorgestrel). The equipment is removed and the patient made comfortable. Findings are discussed with the patient and follow-up arranged as necessary. 8.2 Findings If the hysteroscopy is essentially normal the patient is reassured. Results from investigations will be forwarded to them with a copy of that letter to the GP. Cambridge University Hospitals NHS Foundation Trust Page 4 of 10

5 If hysteroscopy reveals endometrial polyps they should be assessed for suitability for removal: If polyp/s less than 4cm then arrange removal in outpatient clinic using versapoint or Myosure system either at the time of hysteroscopy or book onto the next available slot on receipt of the endometrial sample result. If polyps/s more than 4cm or if the patient is deemed unsuitable for outpatient therapeutic procedure, then arrange inpatient admission for removal under general anaesthetic. If hysteroscopy is suspicious for cancer then an appointment is made for the patient to attend the gynae oncology clinic in approximately one week with the results of their endometrial sample. The possibility of a malignant diagnosis is also raised with the patient in a sensitive manner. If cervical polyps are noted they can be avulsed and sent for histological diagnosis. If the cervical polyp is broad based then an appointment made to attend the colposcopy clinic for polyp removal using loop diathermy. If pyometra is noted and vision is obscured by inflammatory exudate, antibiotics may be given at time of examination. Re-hysteroscope in six weeks, assuming concurrent biopsy is not suspicious of malignancy. 9 Recovery from the procedure Each patient has a minute appointment slot; however each woman is allowed to recover at their own pace. The clinic on Wednesday am is booked with shorter time spaces due to availability of ultrasound scans. The time taken to recover varies from patient to patient. Symptoms of fainting or bleeding may occur and can be dealt with in the appropriate manner. There is an examination room available for patients who need to lie down. Patients are allowed to dress. Sanitary wipes and pads are available for patient use. A written leaflet is given to the patient that explains the aftercare that the nurse has advised for them. It contains telephone numbers for contact should they require advice, information or have any problems following the procedure. Any follow up appointments should be made before the patient leaves the department. Cambridge University Hospitals NHS Foundation Trust Page 5 of 10

6 10 Written information Consent for the procedure must be documented. Consent is verbal and documented on the hysteroscopy flowsheet within EPIC. All specimen requests must be ordered on EPIC as cancer pathway prior to going to the laboratory to ensure that they are reported within the targets (including urgent specimens). Following the procedure a standard or dictated letter should be sent to the GP informing them of the hysteroscopy outcome. 11 Complications 11.1 Uterine perforation Perforation is preventable by never introducing the hysteroscope unless you have vision. Perforation may occur with passage of dilators when dealing with cervical stenosis especially in postmenopausal women Symptoms Patient may experience pain as the dilator goes through the uterine wall. Dilator will pass further than anticipated. Contents of the Pouch of Douglas visible with the hysteroscope Action Remove the hysteroscope. Explain to the woman what has happened. Discuss with consultant if necessary. Consider admission to gynaecology ward for overnight observation. Antibiotics to be prescribed Fainting/ bradycardia/ vaso-vagal attack See management of complications in colposcopy guideline. Cambridge University Hospitals NHS Foundation Trust Page 6 of 10

7 11.3 Bleeding problems From Vulsellum site Apply pressure for 1-2 minutes using swab on a sponge holder. If this does not settle then apple sponge holder/polyp forceps over bleeding point (ie one blade in cervical os and the other blade over the bleeding point). Leave attached to the cervix for 1-2 minutes. This is highly effective and suturing is almost never needed From uterus Reassure patient that the bleeding will usually settle. Consider Tranexamic acid 1gm qds. 12 Results Standard letters are used where possible. Results are communicated to the patient as follows: If histology shows no evidence of pre-cancerous or cancerous changes a letter is sent explaining this and appropriate follow up. If histology is inadequate for histological diagnosis a letter is sent explaining this and appropriate follow up. If results are negative/ inadequate but hysteroscopy showed a polyp, a letter is sent advising them that they will be attending an appointment for an outpatient therapeutic procedure or admission to remove the polyp. If the results are abnormal an appointment is made for the gynae oncology clinic to discuss the results. These results will be managed on an individual basis which may include discussion at MDM Urgent histology If the findings at hysteroscopy are suspicious for malignancy then the histology request should have the date that the results are required for. If this is short notice then the laboratory should be called and informed. 13 Miscellaneous 13.1 Mirena IUS Occasionally a request is made for a Mirena IUS to be fitted following hysteroscopy. Relevant information should be given to the patient and risks discussed with them. They should have a coil string check with their GP six weeks following the procedure. Cambridge University Hospitals NHS Foundation Trust Page 7 of 10

8 13.2 Women referred from genetics At present women who are at high risk developing endometrial cancer are screened annually with ultrasound scan, Ca 125, outpatient hysteroscopy and endometrial sample. A patient pathway for women referred via genetics can be used to determine their management Women who are using tamoxifen In view of increased risk of endometrial cancer associated with tamoxifen therapy, there is a case for heightened vigilance for women with PMB. Women who experience PMB and are on tamoxifen will undergo ultrasound scan, outpatient hysteroscopy and endometrial sample. It should be noted that ultrasonography is poor at differentiating potential cancer from other tamoxifen-induced thickening because of the distorted endometrial architecture associated with long term use of tamoxifen( 1 ). It would be appropriate to discuss the management of patients on tamoxifen with one of the gynae oncology consultants as there may be an indication to review the usage of tamoxifen. This is usually done by writing to the breast cancer team for advice and guidance. 14 Photography For those women who have a digital image taken at hysteroscopy the image is for the purposes of information only and not as teaching aid, and should be stored appropriately within the notes. Specific written consent is required for images that are requested for teaching purposes. 15 Documentation All information is to be recorded into the hysteroscopy flowsheet and patient encounter within EPIC. 16 Training needs/ observers Women are advised that they may wish to have a friend or relative with them. Permission should be sought prior to hysteroscopy if any additional staff non-essential for the purposes of performing hysteroscopy are present. Being sensitive to their concerns helps to improve their experience. Medical students/ observers to the hysteroscopy clinic must be booked in as appropriate. Preferably no more than one observer at a time, however on rare occasions there might be a student (medical or nursing) and a doctor observing. Clinic information is provided for observers to read. Cambridge University Hospitals NHS Foundation Trust Page 8 of 10

9 The information board in the waiting area should inform patients if there are observers present in clinic. 17 Research The PMB service is involved in programmes of research and audit. A continuing commitment to research and audit is an integral part of the activity. 18 Communication Standard letters are used where appropriate. All women who are seen in hysteroscopy who have no action taken must have a letter sent to the GP for information and patient management. 19 Monitoring compliance with and the effectiveness of this document Individual hysteroscopists can audit their own practice. Where there is concern arising about hysteroscopic practice there must be open discussion between colleagues. The best way of ensuring this is a culture of audit within the unit. Regular patient satisfaction audits will be undertaken in order to improve the service. 20 References This protocol has been compiled using information and advice given by the Resuscitation Council (UK). Emergency Treatment of Anaphylactic reactions; guidance for healthcare providers. Available from: Updated January 2008; accessed February 2008 RCOG Standards for gynaecology; Report of a working party (2008) ISBN: P.29 SIGN Publication 61 accessed 2013 RCOG Green-Top guideline 59, March ; accessed 2013 Cambridge University Hospitals NHS Foundation Trust Page 9 of 10

10 21 Associated documents Investigation of women with abnormal vaginal bleeding around/after the menopause patient information leaflet Management of complications in colposcopy guideline Triage of gynaecological oncology fast-track referrals Equality and diversity statement This document complies with the Cambridge University Hospitals NHS Foundation Trust service equality and diversity statement. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Document management Approval: Gynaecological Oncology Business meeting, Division B, 25 October 2016 Owning department: Gynaecological oncology Author(s): Kay Sonnex, Colposcopy / Hysteroscopy Nurse Practitioner Pharmacist: n/a File name: Postmenopausal bleeding guidelines version4 October 2016.doc Supersedes: Version 3, August 2013 Version number: 4 Review date: October 2019 Local reference: Document ID: 4473 Cambridge University Hospitals NHS Foundation Trust Page 10 of 10