NICEr for women HMB Management in Primary Care
Transcript of NICEr for women HMB Management in Primary Care
NICEr for womenHMB Management in Primary Care
Anne ConnollyGPwSI gynaecology
The Ridge Medical PracticeBradford
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Hysteroscopic procedures
020406080
100120
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Hysteroscopy Outcome
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
NovaSure ® Ablation Device
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Novasure ® endometrial ablation
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Novasure ® endometrial ablation
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Novasure ® endometrial ablation
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Novasure ® endometrial ablation
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
NovaSure ®EndometrialAblation
Pre-COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
NovaSure ®Endometrial Ablation
Pre- Post-
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
…and
• Antibiotic prophylaxis
– 3 doses Co-amoxiclav
• Misoprostol if required
– 800ugm 1 hour pre-op
• And…
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Discharge Pack
• Diclofenac 50mg that night
• More CoCodamol that night
• 2 further doses of Co-amoxiclav
• Analgesics as necessary after this
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Analgesia
• Oral pre-med
• Cervical block
• Rescue analgesia
• Maureen
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Pain scores
0
5
10
15
20
25
300 1 2 3 4 5 6 7 8 9 10
mea
n
duringafter
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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)
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Results
• 89 women offered treatment• 79 completed NovaSure under local
89% success
• 7 went on to have GA NovaSure
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Outcomes @ 24 months: 31 women
65
29
9
0 00
10
20
30
40
50
60
70
amen spotting light normal heavy
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Outcomes @ 36 months: 12 women
75
168
0 00
20
40
60
80
amen spotting light normal heavy
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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%)
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
“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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
Future developments
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED
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
COPYRIGHT PRIMARY CARE WOMEN’S HEALTH FORUM – REPRODUCTION/DISTRIBUTION PROHIBITED