nicer for women hmb management in primary care

NICEr for womenHMB Management in Primary Care

Anne ConnollyGPwSI gynaecology

The Ridge Medical PracticeBradford

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Gynaecology service developments• PwSI clinics/Triage

• Consultant support• Nurse led AUB clinic• University accredited diploma

• Hysteroscopy• Direct access• Therapeutic hysteroscopy

• Pathway development• AUB• Direct access sterilisation• Incontinence• Infertility

COPYRIGHT N’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED PRIMARY CARE WOME

a NICE experience for women

Recommends:

Woman centred care

NICE HMB Clinical guideline

no 44


Versascope ®


Hysteroscopic procedures

020406080

100120


Polyp resection


Hysteroscopy Outcome


NovaSure ® Ablation Device


Novasure ® endometrial ablation


NovaSure ®EndometrialAblation

Pre-COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

NovaSure ®Endometrial Ablation

Pre- Post-


Patient selection for endometrial ablation

• Heavy Menstrual Bleeding

• Family complete

• IUS failure or declined

• Tolerates OPH and EB

• Histology normal

• Patient choice

• No pre-treatment necessaryCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

LA protocols

• Have lunch• Arrive 90 minutes before• Oral Pre-med

– Diclofenac 100 mg, Cyclizine 50mg, CoCodamol30/500

• 4 ampoules 3% mepivacaine– Deep cervical block– Cx to Hegar 8

• N2O available if needed• Someone to drive them home


…and

• Antibiotic prophylaxis

– 3 doses Co-amoxiclav

• Misoprostol if required

– 800ugm 1 hour pre-op

• And…


Discharge Pack

• Diclofenac 50mg that night

• More CoCodamol that night

• 2 further doses of Co-amoxiclav

• Analgesics as necessary after this


Patient demographics

• Mean age 41 (32 – 54)• All stages of cycle• 3 nullips (3.5%)• 17 with prior LSCS (21%)• 71 with Vas or Sterilisation (80%)• Mean treatment time 88.0 (48 – 120) secs


Analgesia

• Oral pre-med

• Cervical block

• Rescue analgesia

• Maureen


Pain scores

0

5

10

15

20

25

300 1 2 3 4 5 6 7 8 9 10

mea

n

duringafter


Pain scores

• Visual Analogue Score• During NovaSure• Mean 5.3 range (1 – 9)

• At discharge from WWP 1 hour later• Mean 0.9 range (0 – 5)


Problems

• 79 women treated successfully– 8 women vasovagal post treatment (10%)– 3 women admitted for pain control (4%)– 3 passed decidual casts– 2 women vomited


Results

• 89 women offered treatment• 79 completed NovaSure under local

89% success

• 7 went on to have GA NovaSure


Results• 10 not treated with Novasure under LA

– 4 Vasovagal

– 3 Inadequate pre-op assessment

– 1 failed cx dilatation – ThermaChoice

– 1 false passage

– 1 unable to seat deviceCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

Outcomes @ 12 months: 61 women

64

23

11

1 00

10

20

30

40

50

60

70

amen spotting light normal heavy



65

29

9

0 00

10

20

30

40

50

60

70




75

168

0 00

20

40

60

80



Subsequent interventions• 9 women have needed further interventions

11%– 4 RBA to residual cavities– 3 VH - HMB– 1 TAH spotting– 1 subtotal for pain with Asherman’s

• ie only 5 women have needed major surgery

6%• 1 death – pancreatic cancer


Outcomes• Treated 79 women

• 88% have amenorrhoea or spotting @1 yr– 92% @ 2 years and 91% @ 3 years

• Only 9 woman were not satisfied with just NovaSure (12%)

• Only 5 women needed major surgery in the 4 years since we started (6%)


“No longer feel washed‐outand tired. I feel like I’ve got anew lease of life” Shelley

“I feel confident wearing white now – in fact I’ve worn white trousers today!” Maxine

“Having the NovaSureprocedure has saved my marriage.” Anne

“Discovered new interests, donating blood again & financially better off”Cheryl

“I have already told a few of my friends – I would recommend this to all women who have problems” Elaine

“I’ve got my life back – try NovaSure before you try anything else” Jacqui

PR – NovaSure DVD


Future developments


ve


Conclusions

• Out-patient diagnostic and therapeutic hysteroscopy

services are safe

• Treatments are well tolerated under local anaesthesia

• Can be performed in primary care

• Good results

• Extra choice for women

• Closer to home


www.pcwhj.com www.primarycarewomenshealthforum.orgCOPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED

nicer for women hmb management in primary care

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