The Changing Face of Gynaecology in Primary Care

John Short

Obstetrician and Gynaecologist

Christchurch

john.short@oxfordwomenshealth.co.nz

• What

• Why

• How

• Whether it works or not

• What the future holds

• The GP is doing a lot more

• Initiating investigations

• treatment

• Procedures

• Follow up

• The gynaecologist is NOT doing less…

• …but he/she is doing a bit different, so has less time…

• More “hands-on”• More supervision

• More practical procedure focused

• More complex procedures

But why?

Other reasons

• Medico-legal pressure

• Trainee issues

• Increased sub-specialisation

• Recruitment / retention challenges

• Capacity

• Expectations

• Relative increase in specialists time

• To concentrate on more specialised things (eg surgery)

• Transferring less specialised things to GPs

How

• Investigations

• Treatments

• Procedures

• Follow up

Online resources

• Canterbury initiative

• healthpathways

Investigations

• To facilitate ongoing management of patient in primary care or determine if referral necessary

• To streamline management in partnership with secondary care• Referral inevitable

• Delays inevitable

• Can have investigations whilst waiting

examples

• Fertility• 20 years ago, GP would refer and specialist would initiate investigation

• Even simple stuff like bloods and semenalysis

• Led to more delays

• Now GP can theoretically do all tests prior to referral• Ovulation

• Semenalysis

• Tubal patency

examples

• Pelvic ultrasound• Early pregnancy

• Menstrual problems

• Pelvic pain• Acute

• Chronic

pelvic ultrasound

• Know what you’re looking for (and why you’re looking for it)

• Know what it can tell you

• Know what it can’t tell you

• Know what it can tell you that you’re not looking for

• Is it going to change your management?

What it can tell you?

• Uterine dimensions

• Endometrium/uterine cavity

• Myometrium

• Adnexae/ovaries

• Other stuff

Eg ectopic pregnancy

• Uterine dimensions normal

• Endometrium/uterine cavity ‘empty’/thickened endo/pseudosac

• Myometrium unchanged

• Adnexae/ovaries mass/corpus luteum

• Other stuff free fluid

Menstrual problems

• Uterine dimensions normal or enlarged

• Endometrium/uterine cavity thickened endometrium/polyps

• Myometrium fibroids/adenomyosis

• Adnexae/ovaries

• Other stuff suitable for mirena

if a biopsy required

What it can’t tell you

• The diagnosis

What it can you that you’re not looking for

• Thickened endometrium

• Ovarian cysts

• Adenomyosis

• Endometrial polyps

treatment

• Menorrhagia

• Overactive bladder

• Stress incontinence

• prolapse

treatment

• Menorrhagia medication, or mirena

• Overactive bladder lifestyle, anticholinergics

• Stress incontinence lifestyle, physiotherapy

• Prolapse physiotherapy, ring pessaries

menorrhagia

• Exclude pathology

• Commence treatment• reassure

• Tranexamic acid

• Progesterones

• Contraception

• Mirena

Overactive bladder/incontinence

• MSU, Bladder diary, physical examination

• Commence treatment• Weight loss

• Oestrogen for vaginal atrophy

• Modify fluid intake, dietary triggers (bladder friendly foods)

• Ring pessary for prolapse

• Anticholinergics (solifenancin available by special subsidy)

• Physiotherapy

2417

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Physio patient selection

• >2 leakages/day

• Psychotropics

• Symptoms >5yrs

• +ve stress test (first attempt)

• >2pads/day

• Significant (untreated) prolapse

• (urodynamic data)

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PHYSIO

• 50% significant improvement

• 25% mild improvement

• Age/BMI not predictors

• 4 M’s

• Patient choice

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procedures

• Pipelle

• Mirena

• Ring pessary

Pipelle Endometrial biopsy

• Indication

• Technique

• interpretation

Indication

• Risk of endometrial cancer/hyperplasia• Abnormal bleeding with risk factors

• Postmenopausal, endometrium >5mm

• obesity

• nulliparity

• Intermenstrual bleeding

technique

• Consider pre-treatment with NSAID or misoprostol

• Explain to patient, include pain

• Show device

• Insert speculum

• Visualise cervix

• Insert pipelle to external os and advance to fundus (will stop)

• Withdraw plunger

• Rotate, withdraw, advance (without removing)

• Remove when full (or not filling)

• Place in fomalin

• repeat

• Antiseptic optional

• Local anaesthetic optional

• May require counter traction by grasping cervix (more oomph)

• Device may require grasping closer to tip to maintain ‘integrity’ (and get more oomph)

• Note depth of insertion (equates to uterine length)

• Note relative position of ‘active’ part of tip to ‘handle’- will help ensure comprehensive sampling of all endometrial surfaces

• Don’t require a scan first

Equipment list

• Drugs

• Speculum

• Pipelled

• Tenaculum/valsellum

• Specimen pot

• Sponge holder

interpretation

• False negative rate low

• Relate result to clinical picture

• Hyperplasia may have co-existing malignancy

• Proliferative endometrium abnormal in postmenopause

• Won’t reliably sample polyps

Mirena IUS

• Good contraception

• Good treatment for menstrual problems, including dysmenorrhoea

• Administration of progesterone for HRT

insertion

• Consider pre-treatment with NSAID or misoprostol

• Explain to patient, include pain

• Show device

• Insert speculum

• Visualise cervix

• Clean cervix

• Consider LA

• Consider counter-traction and dilatation

• Measure uterine length

insertion

• Prepare device

• Set depth with marker at measurement (bottom of marker to allow device arms to spring out)

• Insert, advance and stop 1cm short

• Release arms and advance to fundus

• Cut strings (not too short)

• Consider prod with sound/dilator in cervical canal

• Scan prior

• Swabs prior

• Concurrent pipelle

• 6 week check

pessaries

•

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Pessaries

• useful for anterior and central compartments

• less effective for posterior compartment

• At 1 year similar improvement in urinary, bowel, sexual and QOL measures when compared to surgery

• median duration of use 2 yrs

• possible to avoid surgery

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Reasons for discontinuation

• Inconvenient

• Inadequate relief of symptoms

• Uncomfortable, ulceration, bleeding, discharge

• Elected for surgery

• Unable to remain in place

• Difficulty urinating (or bowels)

• Incontinence increased

• (different sizes or shapes may help)

Sizing up ring pessaries

• insert fingers deep into the posterior fornix

• Make note of where the hand comes into contact with the pubic bone

• Compare to pessary.

I

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insertion

• Reduce dimensions

• Lubricate

• Insert

• Will spring open

• Nudge into position

• Should be snug but not tight

• Should ‘suspend’ from behind pubic bone

to posterior fornix

• regular oestrogen

• annual review

Follow-up of gynae patients

• Postop care

• Long term cancer follow up

But does it work

• Depends how its measured

• Pmb study/pipelle audits

• SIS audit

• London oab study

PMB

• Transvaginal ultrasound scan

• Endometrial biopsy if Endometrium > 5mm

• Hysteroscopy if difficulties/doubts/ongoing issues

PMB

• 191 cases

• 110 ET <5mm

• 81 ET >5mm

• 48 pipelles (4 cancers plus 14 others referred to secondary care)

PMB

• 140 women managed solely in community (110 scan only)

• No cancers missed (12 month review)

• Median time to complete pathway 28 days

• Cancer diagnosis 22.5 days (community) vs 65 days (hospital)

Saline infusion sonography

• Half way between pelvic ultrasound and hysteroscopy

• More accurate that ultrasound

• Less expensive than hysteroscopy

• High false positive rate using ultrasound diagnosis of endometrial polyps

• Leading to many unnecessary hysteroscopies

• Pilot study to determine if SIS can reduce this

• 9.3 SIS needed to avoid one hysteroscopy

• xs cost of $2482 per hysteroscopy avoided

The future

• Minor surgery

• Colposcopy

• Ovulation induction

Ovulation induction

• Clomiphene 50mg OD day 2-6

• Day 21 progesterone

• Day 10 oestrogen

• Day 14 LH

• Ultrasound monitoring

The future…

• Reduced access to elective services

• Moh targets

• Strict scoring

• cpac score

The end

• Thank you

• john.short@oxfordwomenshealth.co.nz