Hysterosalpingogram- the patients perspective

Maggie Williams

Clinical Lead Nurse Radiology

Gateshead Health NHSF Trust

Hysterosalpingogram

• Outpatient procedure

• Varying levels of importance

• Doctor who is free, radiology/gynaecology consultant, specialist nurse.

• Fitted in around other procedures.

Patients experience before appointment

• 18 months to 2 years infertility.

• Highly emotional

• Referred via GP

• Gynaecology OPD

• Referral for HSG

Following referral for HSG

• Written information leaflet

• Verbal information at Gynae OPD

• Letter asking to telephone for appointment on first day of menstrual cycle.

How well does this prepare our patients?

• Still asked:

• Where do you put the injection?

• How do you get the dye into my tubes?

• Do I have to take my pants off?

• Will it hurt?

• My friend says it is awful.

This made us think:

• Are we preparing our patients well enough?

• What do our patients want from us?

We decided to investigate

2 areas:

• Women’s perception of pain

• Women's expectations and emotions around time of HSG

Perception of Pain

Audit of

• Pain during the HSG

• Type and length of pain

Patient audit

• 60 patients asked to complete and return questionnaire

• 45 responses

ResultsType of Pain(%)

0

5

10

15

20

25

30

35

40

45

50

Cramps

Stabbing pain

Cramps &stabbing pain

Dull ache

Other

Results (cont) Duration of Pain

0

5

10

15

20

25

30

Only duringHSG

A couple ofhours

All day

A number ofdays

Results (cont)Pain Score(%)

0

2

4

6

8

10

12

14

16

18

Score of 10

Score of 9

Score of 8

Score of 7

Score of 6

Score of 5

Score of 4

Score of 3

Score of 2

Score of 1

Summary

• The majority of patients experienced crampy pain for the duration of HSG.

• A smaller but significant number of patients had pain for length of time after HSG

• Majority of patients had pain score of 5

or more.

Changes.

Amended patient information leaflet to advise patients to take simple analgesia prior to procedure.

Re audited patients.

Second audit.

Same audit with additional questions:

• Did you take any painkillers before the HSG?

• What type of painkillers?

• 35 responses.

ResultsType of Pain (%)

0

5

10

15

20

25

30

Cramp

Stabbing

Cramp &Stabbing

Dull ache

Other

Results (cont) Duration of Pain

0

2

4

6

8

10

12

Only duringHSG

A couple ofhours

All day

A number ofdays

Results (cont)Pain Score (%)

0

5

10

15

20

25 Score of 10

Score of 9

Score of 8

Score of 7

Score of 6

Score of 5

Score of 4

Score of 3

Score of 2

Score of 1

Type of Analgesia taken.

0

2

4

6

8

10

12 Not Stated

Anadin Extra

Ibufren only

Paracetamol &Codeine

Paracetamolonly

Ibufren &paracetamol

Summary of results

• 68% of patients took analgesia prior to HSG examination

• 97% of patients still experienced pain during or after HSG.

• 34% during HSG only

• 34% for a couple of hours, but

• 20% for a number of days after.

Summary of results (cont)

• 82% of original group and 80% of second group scored pain 5 or higher

• Pain scores of those who hadn’t taken analgesia ranged from 2-10.

• Were mainly towards higher end of scale.

• Use of simple analgesia in this group had little effect on pain scores.

Summary of results (cont)

• Women who took simple analgesia prior to HSG seemed to have little benefit.

• Pain scores 80% 5 or more

• This did not correlate with our perception of patient pain

Other studies

• Duffy et al 2008:

• Reviewed current practice in 104 UK centres.

• 50% gave formal advice re pain relief

• 35% offered no analgesia

• Did not review the effect of analgesia

Women's emotions and expectations

We decided to progress our work to look at:

• What are women's emotions and expectations of HSG?

• Do we meet their needs?

Research Study

• Patients referred for HSG

• Sub fertility

• Referred from within Trust

Aims

• To inform our knowledge about the specific needs of this group of women.

• Discover the underlying issues that women have at the start of sub fertility investigations

• Raise awareness of the need of research by nurses in areas where they are practicing.

Conclusion of literature review

• High incidence of anxiety and depression in sub fertile women

• Low incidence of qualitative studies addressing this situation

Method

• Qualitative study using grounded theory research

• We used interviews and scheduled them prior to HSG

• During interview we asked 12 Core questions allowing the women to expand their answers to each question

• 10 Recorded Interviews: approx one to one and half hour duration.

Question Categories

• Background to their sub fertility or

their story• Expectations: pain, dignity, results.• Importance of HSG to them• Formal support from professionals• Informal support from families

Results

A number of themes developed

• Written information does not meet all of the patients needs

• Women see HSG as a defining moment

• Sub fertility is still a taboo subject

Written information does not meet all of women's needs.

• Information giving is not as simple as often thought

• Written information not always read and often produces additional questions

• One woman said “I was horrified” after seeing the information leaflet

Written information does not meet all of women's needs. (cont)

• Verbal explanation needed to support written information

• When asked “..do you have any questions” at an out patient appointment women do not know if they have any questions because they have not read the information leaflets

Women see HSG as a defining moment

• Women rated the importance of HSG between 8 and 10. 10 being the most important

• Signpost to further treatment

• Watershed moment

• ‘No progress can be made without it’

Sub fertility- a taboo subject

• Loss of well being• Loss of self confidence• Anticipatory grief at potential

childlessness.

Sub fertility- a taboo subject (Cont)

• Women found infertility hard to talk about.• ‘I don’t want to be the source of other

peoples gossip’

Anxiety permeated all

themes

Conclusions directed towards

anxiety reduction

Implications for Practice

• Recognition that written information meets only part of the information requirements of women.

• Women need verbal support from professionals along with written material: this allows their specific needs to be addressed leading to an increased ability to cope and reduction in anxiety

Implications for Practice

• The role of the Advanced Nurse Practitioner should be reviewed

• Nurse Practitioners can take a lead• Nurse Practitioners can use their role to

advance education and communication between all specialities involved in the sub fertility field

• This would produce a seamless service

Implications for Wider Practice

• Health care professionals should recognise that written information may not reduce patient anxiety levels – verbal support should be available to compliment the patient information leaflet.

• Sub fertility should stop being a taboo subject.

• Raising the profile of focus groups.

Overall Conclusion

• Women do find HSG painful

• Do we offer effective analgesia?

• Do we meet women's information needs?

• Do we address women's anxieties?

• Do we prepare HSG patients adequately?

References

• Duffy,JMN, Gaity A, Watson AJS (2008) Pain Relief during Hysterosalpingography: A national survey.Human Fertility 11(2) 119-121

• Williams M, Green L & Roberts K (2010) Exploring the needs & expectations of women presenting for hysterosalpingogram: A qualitative study.

Currently unpublished.

Any Questions?