Post on 08-Dec-2021
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
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a NICE experience for women
Recommends:
Woman centred care
NICE HMB Clinical guideline
no 44
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Hysteroscopic procedures
020406080
100120
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Hysteroscopy Outcome
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NovaSure ® Ablation Device
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Novasure ® endometrial ablation
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Novasure ® endometrial ablation
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Novasure ® endometrial ablation
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Novasure ® endometrial ablation
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NovaSure ®EndometrialAblation
Pre-COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
NovaSure ®Endometrial Ablation
Pre- Post-
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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
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…and
• Antibiotic prophylaxis
– 3 doses Co-amoxiclav
• Misoprostol if required
– 800ugm 1 hour pre-op
• And…
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Discharge Pack
• Diclofenac 50mg that night
• More CoCodamol that night
• 2 further doses of Co-amoxiclav
• Analgesics as necessary after this
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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
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Analgesia
• Oral pre-med
• Cervical block
• Rescue analgesia
• Maureen
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Pain scores
0
5
10
15
20
25
300 1 2 3 4 5 6 7 8 9 10
mea
n
duringafter
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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)
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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
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Results
• 89 women offered treatment• 79 completed NovaSure under local
89% success
• 7 went on to have GA NovaSure
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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
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Outcomes @ 24 months: 31 women
65
29
9
0 00
10
20
30
40
50
60
70
amen spotting light normal heavy
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Outcomes @ 36 months: 12 women
75
168
0 00
20
40
60
80
amen spotting light normal heavy
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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
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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%)
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“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
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Future developments
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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
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