Mr Doug BarclayGynaecologist

Ascot Central Women’s Clinic

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)

Mr Simon EdmondsGynaecologist

Middlemore Hospital

Auckland

Practical Mirena Insertion and Pipelle Endometrial Sampling

Simon EdmondsDouglas Barclay

Orna McGinn

Why are we doing this session?

Give you a taste…..

Improve your skills

Improve the patient journey

Feedback

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

Why in Primary Care?

1 in 16 women age 30 – 49 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%

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

Diagnosis of exclusionDysfunctional uterine bleeding, acute PID

Fibroids outside cavity or submucous…

Polyps…

Endometrial hyperplasia..

Endometrial cancer..

Cervical cancer

Clotting abnormalities etc…

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 (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

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?

Secondary/Tertiary Care

Interface

Providing the tools to assist primary care in:

diagnosis

referral for further tests

recommended treatment pathways

referral for specific surgical treatment

Tools and resources

Appropriate training -guidelines

-practical training in pipelle/mirena

Appropriate access to tests -ultrasound

Appropriate renumeration/time

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?

Who do you investigate further and how?

Ultrasound scanning……………..

Endometrial pipelle sampling..

ET

Polyps Fibroids

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

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

**BMI

**Age

Has it worked?

Slowly…..!!

Why not? Access to funding/remuneration

Mismatch in payment

Lack of a GP ‘champion’

Dissemination of project

90 patients in 18 months on pathway

?10-14 complete

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

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

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

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

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

Pipelle Sampling:

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..

Mirena insertion:

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