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Gynaecological G

uidelines

Gynaecological Guidelines

Management of Cervical PolypsCervical polyps are common coincidental findings in women undergoing cervical screening. Inthe asymptomatic woman they are almost always benign. They consist of an overgrowth of theendocervical columnar epithelium and are usually solitary although a small number may coexist.More rarely a submucosal uterine fibroid on a long pedicle may be extruded through the cervicalcanal.

Removal of a cervical polyp up to 2cm long by 1cm wide is a simple painless procedure requiringlittle skill and is not associated with significant bleeding and can be easily done in the primarycare setting. Assuming this is a coincidental finding a vaginal speculum will already be inplace.

If the intention was to take a cervical smear this should now be performed.

The vaginal speculum may be replaced with a self-retaining one thus freeingup the examiner.

The polyp should be grasped with a polypectomy forceps and twisted severaltimes. The polyp can now be pulled upon and avulsed. The vaginal speculumshould be removed. Make sure to use polyp forceps rather than spongeholding forceps

The polyp should be placed in a specimen pot with fixative and sent to apathology department with a completed request form for histologicalexamination.

The patient should be reassured and advised how and when she will learnof the pathology findings.

Patient should be warned to expect some vaginal bleeding for up to 24 h.

In the unlikely event that the patient experiences significant discomfort orthere is difficulty, the procedure should be abandoned and the patientreferred to a gynaecologist.


Vaginal Discharge

In adolescence the cyclical hormonal surges alter the shape of the cervix so that it “pouts”exposing the thin walled columnar, glandular epithelium. This looks red compared with thesurrounding pink cervical covering of multilayered squamous cells since the underlyingvascular tissue is being viewed through a clear window as opposed to a frosted glass one.This has traditionally been referred to as a cervical “erosion”, a term which conjures up animpression of pathology where none exists. This cervical eversion may be encouraged topersist in women taking the combined oral contraceptive pill but normally with the passageof time the exposed columnar epithelium undergoes physiological metaplastic change to asquamous covering. A little vaginal discharge is normal consisting of desquamated cervicaland vaginal cells increasing somewhat premenstrually. Midcycle the cervical mucus is clearand stringy facilitating the passage of sperm into the uterus. Otherwise it is thicker andopaque acting as a barrier to the passage of bacteria beyond the vagina. Rarely cervicaleversion is associated with excessive mucous discharge warranting treatment. As metaplasiaproceeds cervical crypts become closed off resulting in multiple physiological mucus retentioncysts, Nabothian follicles. They may be yellow or pearl like in appearance and are commonlyseen when a cervical smear is being taken or on ultrasound, CT or MRI scan.

Nabothian Follicles are of no consequence and their presence does not constitute areason for gynaecological referral. They are not pedunculated and should not, therefore,be confused with cervical polyps.


Vaginal Discharge

Patient presentation

GP

Sexual history

Examination� external

� pelvic

� visualise cervix and

check smear is up to

date

� high vaginal and

endocervical swabs

including a check for

chlamydia

If full STI testing is

required refer to GUM

Check for foreign

body (eg tampon) and

remove if present

mucopurulent

discharge

review lab

results

cervical

ectropioncervical

polyp

if postmenopausal

gynaecology

+ve

review

therapy

-ve

for infection

GP

If swabs negative and

examination negative:

discharge, reassure -

likely physiological

if discharge

persists or

Post coital

bleeding

refer for

consideration

of cervical

cautery. Any

suspicious

appearance;

refer

colposcopy

remove –

see

introductory

section for

management

of cervical

polyps

Vaginal Discharge – Patient Pathway


Sterilisation – Patient Pathway

Patient wishes

sterilisation


GP

Discuss alternative

contraception

Vasectomyfailure rate 1 in

2000; can be

done under local

anaesthetic; few

complications

GP/Family Planning Clinic

Patient’s attention should be drawn to the

following, which will also be discussed in

Secondary Care:

� General anaesthetic – usually undertaken

laparoscopically with clips as day surgery

� Age – sterilisation is performed in women < 30 yrs

only in exceptional circumstances (increased regret

rates in under 30s

� Laparotomy – may be required if surgical

complications are encountered

� Irreversible – difficult to reverse and NHS may not

fund reversal

� Failure rate – 1/200, increased risk of ectopic with

any subsequent pregnancy

� Surgical risks – greater in high-risk women (BMI,

abdominal scars, medical disorders)

� Continue current contraception until after the

procedure

� Periods – will be unchanged (unless on hormonal

method pre-op or an IUCD is removed)

Implanted

progestogen

only device>99% effective;

lasts 3 years;

local anaesthetic;

initial menstrual

upset; weight

gain

Intra-uterine

progestogen

only device>99% effective;

lasts 5 years;

periods less

heavy; may

cause initial

menstrual upset

Injectable

progestogen

only

contraceptive>99% effective;

lasts 12 weeks;

periods may be

irregular or stop;

weight gain

Intra-uterine

contraceptive

device>99% effective;

lasts 3 to 10

years depending

on type; periods

heavier and more

painful

Oral

contraceptiveCOCP >99%

effective; periods

less heavy; POP

99% effective;

compliance issues

If decision to

consider female

sterilisation

Refer for

sterilisation

If decision taken

to perform

vasectomy, refer

to Urology or

Family Planning

Clinic


Post-Menopausal Bleeding – Patient Pathway

GP

Vulvo-vaginal

examination and

speculum

Pelvic examination

Smear only if due

Post-menopausal

bleeding symptoms


Persistent post-menopausal

bleeding despite negative

findings warrants direct

referral to Gynaecology on 2

week wait

Normal

Gynaecology

? Cervical

carcinoma

On

Tamoxifen

Cervical

polyp

Pelvic and transvaginal

ultrasound

Remove if

appropriate

If scan not

available

within 2

weeks

See

ultrasound

algorithm

Gynaecology

Gynaecology

Refer Refer to

colposcopy /

rapid access /

triage / fast

track clinic


Ultrasound algorithm for the management of patientswith post-menopausal bleeding – Patient Pathway

No HRT ≥ 1 year or

continuous combined HRT

On sequential combined HRT

(or within 1 year of stopping)

Endometrium

> 4mm

Endometrium

< 4mm

Refer

Gynaecology ? other

abnormal

findings

Endometrium

≤ 5mm

Endometrium

> 5mm

Refer

Gynaecology

No Yes

Reassure patient

but encourage

early reporting of

persistent

symptoms

FibroidsSimple cyst(s)

≤ 5cm

Other adnexal

mass

Ca125Refer

Gynaecology

Ca125 > 30

Refer

Normal

Re-scan 4-6

months

No Change,

reassure patient,

do further

investigations

increase in

size or

change in

morphology

Refer


Infertility – Patient Pathway

Remember:Rubella status

Folic acid

Drug history

Cervical smear

history

Chlamydia check

If female with BMI

>30 advise weight

loss

Advise regular

intercourse (2 or 3

times per week)

Do not encourage

use of temperature

charts or LH

detection kits

Couple present with

infertility


GP

History and

examination of both

partners

Advise both

partners on

smoking and

drinking

Female Male

Confirm ovulation

with mid-luteal

progesterone level.

No need to

measure thyroid

function or prolactin

if cycles are

regular.

Arrange for at least

one semen sample

to be sent to lab for

analysis

GP

Discuss results with

couple

Normal

results

Abnormal

results

Defer referral until

couple have been

trying to conceive

for 12 to 18 months

Gynaecology

FemaleAge over 35

Amenorrhoea/oligomenorrhoea

Previous abdo/pelvic surgery

Previous PID/STD

Abnormal pelvic examination

Consider early

referral if...

MalePrevious genital pathology

Previous urogenital surgery

Previous STD

Varicocoele

Significant systemic illness

Abnormal genital examination

Consider

referral to

Urology


Pelvic Pain – possible causesGynaecological

Primary dysmenorrhoeaEndometriosisAdenomyosisOvarian Cyst

Key QuestionsIs pain: cyclical; dysmenorrhoea; pre-menstrual; dyspareunia?Is menstrual cycle abnormal?Cyclical pain on defecation

GastrointestinalInflammatory bowel diseaseIrritable bowel syndrome

Key QuestionsAltered bowel habit?PR bleeding?Weight loss?Vomiting?

ExaminationAbdominal plus pelvic, FOB, FBC, Coeliac antibodies, CRP

MusculoskeletalKey Questions

Pain related to position or movement?

UrologicalInterstitial cystitis

Key QuestionsSpasmodic pain related to full or emptying of bladder?

ExaminationAbdominal plus pelvic, check urine, exclude infection

PsychosomaticConsider alongside rather than after organic causes

Key QuestionsPast history of mental health problems, depression, anxiety?Current life events, stress factors?History of medically unexplained symptoms?


Pelvic Pain – Patient Pathway

Pelvic pain symptoms in

pre-menopausal woman


GP

AssessmentIs the pain (or was it initially) menstrual or

pre-menstrual?

Is it new/altered dysmenorrhoea?

Is there (or was there initially) deep

dyspareunia?

Is the menstrual cycle abnormal?

Lack of GI symptoms?

Consider

non-gynaecological

cause

Bimanual

examination

Yes No

Exclude/treat

infection (high

vaginal and

endocervical swabs

including

Chlamydia check)

Uterus fixed/tender

or adnexal mass

Arrange ultrasound

and refer as

appropriate

Gynaecology

Normal

TVS

Normal FibroidsSimple cyst

<5 cm

Treatment options

COCP or

progestogen-

only

contraceptive

(oral,

injectable or

intra-uterine

Non-opiate

analgesia,

Paracetamol,

NSAID

Consider

psychological

factors. Anti-

depressants?

and and

Review in 3

months

GP

Symptoms controlled?

Continue

If symptoms

persist

If tender or

endometriosis

suggested or

complex cyst


Irregular Bleeding – Patient Pathway

Heavy vaginal

loss over 40 yrs

old: see Heavy

Menstrual Bleed

Pathway

GP

1. Exclude pregnancy

2. Bimanual examination

3. Visualise cervix, smear

only if due

4. Check for chlamydia

5. Review contraception


Uterus palpable abdominally:

see Abdomino-pelvic Mass

Pathway

Post-coital

bleeding

Inter-menstrual

bleeding

Irregular

bleeding symptomsMay be: Intermenstrual;

post-coital; more frequent,

including irregular cyclicity;

prolonged.

Is not: Oligomenorrhea;

post-menopausal bleeding.

Cervical polyp: see protocol

for management of Cervical

Polyps in the introductory

section

Normal smear

and cervix

Abnormal

smear or cervix

ObserveRefer to

colposcopy

If persistent

(over 2

months)

follow

intermenstrual

bleeding arm

of this pathway

Complete 3 month

menstrual blood loss

chart

GP

Under 40:Treat with oral

contraceptive or

Norethisterone 5mg tid

days 5-25 for 3 to 6

months

Refer to

Gynaecology

No improvement


Heavy irregular vaginal bleeding in women over 40 –Patient Pathway


Symptoms of heavy

irregular vaginal

bleeding in a woman

over 40 years old

Refer to Gynaecology


Abdomino-pelvic Mass

Following the menarche the first few cycles are commonly anovulatory, resulting in irregularityand heavy menstruation. This is normal and self limiting. Thereafter, the cycles settle into aregular ovulatory pattern with several ovarian follicles developing in any one cycle duringthe proliferative phase when oestrogen is producing endometrial growth. Usually one folliclewill predominate reaching some 2-3cm in diameter before rupturing releasing the ovum.The other follicles will shrink leaving the ruptured follicle to become the corpus luteum, anendocrine gland with a well developed blood supply into which progesterone is secreteddirectly. The progesterone prevents further growth of the endometrium preparing it for thearrival of a fertilised ovum. If this does not happen the corpus luteum atrophies approximately14 days later, the levels of oestrogen and progesterone fall and the endometrium is shed asa period.

Developing ovarian follicles and the corpus luteum are visible on ultrasound examinationand are commonly referred to as cysts which indeed they are being fluid filled structures inthe former and occasionally similarly when there has been bleeding into the latter.Occasionally ovulation does not take place and the lead follicle continues to grow in diameter.

In an asymptomatic woman with functioning ovaries the coincidental finding of ovariancysts up to 5cm in diameter does not warrant gynaecological referral.


Abdomino-pelvic Mass – Patient Pathway

GP

Assessment

Abdomino-pelvic mass palpable or

found on ultrasound scan


Partly cystic,

partly solid or

multilocular or

irregular

Unilateral or bilateral, cystic,

unilocular, smooth, regular

Arrange

USS/TVS

Adnexal/ovarian

cause. Check

Ca125

Fibroid on scan

Minimal or

no

symptoms

Menorrhagia

or pressure

symptoms

< 5cm in

diameter

≥ 5cm in

diameter

Follow-up

scan in 4-6

months

GP

Reassure

Refer to Gynaecology

If pain

present

Suspect

endometrioma

or

complications

to simple

ovarian cyst

Minimal or no

symptoms:

Pre-menopausal

with Ca125 <

30Ku/l

Suspect simple

or functional

ovarian cyst

≥ 5cm in

diameter

<5cm in

diameter

Especially if

ascites present

and/or Ca125

> 30Lu/l

Suspect

ovarian cancer

regardless of

symptoms or

size

Urgent referral

2 weeks

Gynaecology

Abnormal

Ca125 >30

Normal Ca125 <30

Normal

finding


Six month’s history of secondary amenorrhoea – PatientPathway

6 months history of secondary

amenorrhoea symptoms


Blood testsFor all:

FBC, TFT, FSH, LH, Oestradiol,

Prolactin, Free Androgen Index

(FAI), Testosterone, Sex hormone

binding globulin (SHBG)

ExaminationBMI, hirsutism, severe acne

GP

Exclude pregnancyAssess:

History

Menstrual, sexual, contraceptive, medical,

drugs, psychiatric (including eating

disorders), diet, recent weight loss, stress,

travel, exercise

Check BMI

Refer to Infertility

Pathway

Wishes for pregnancy

See overleaf for action

on results


Six month’s history of secondary amenorrhoea – Actionon results

All normalRaised FSH and

LH

If PCOs

suspected, ie

raised LH/FSH

ratio, hirsuitism

and FAI >6Reassure, offer

review in 3

months

If amenorrhoea

persists, repeat

all tests and

refer

Gynaecology

Consider

menopause

Low FSH, LH,

low oestradiol,

raised prolactin

Prolactin > 1000

? Prolactinoma.

Refer to

endocrinology

Prolactin < 1000

Repeat prolactin

(if 400-1000) and

give COCP

Weight loss if necessary. Consider

cosmetic advice for hirsuitism

Needs

contraception:

COCP, POP or

intra-uterine or

implanted

progestogen-only

device

Hirsuitism/acne:

cyprotone and

ethinyloestradiol

combination or

COCP

Re-assess in 12

months

Amenorrhoea

Gynaecology

TVS to confirm

PCOS


Care pathway for heavy menstrual bleeding

GP

Woman presenting

with HMB


Take history

Take full blood count

Structural or histological

abnormality possible

No structural or histological

abnormality suspected

Physical examination

No abnormality/fibroids

<3cm diameter

Consider endometrial

biopsy for persistent inter-

menstrual bleeding, and in

women >45, treatment

failure or ineffective

Pharmaceutical

treatment (see table 1)

Uterus is palpable

abdominally or pelvic

mass

Consider imaging,

first-line transvaginal

ultrasound

Consider physical

examination

Consider second

pharmaceutical

treatment if first

fails

Provide information to woman and

discuss treatment options

Other treatments have

failed, are contraindicated

or declined

Desire for amenorrhoea

Fully informed women

requests it

No desire to retain uterus

and fertility

Severe impact on quality of

life, no desire to conceive,

normal uterus, ± small

fibroids (<3cm diameter)

Severe impact on quality of

life

Fibroids (>3cm diameter)

Hysterectomy (see table 2)

(don’t remove healthy

ovaries)

Endometrial ablation

(see table 2)

Myomectomy

(see table 2)

Uterine artery

embolisation

(see table 2)


Table 1 Pharmaceutical treatments proven to reduce menstrual bleeding1

Discuss hormonal and non-hormonal options and provide time and support to help thewomen decide which is the best option for her.

Firs

t line

Second

line

Third

line

Oth

er

Firs

t line

Levonorg

estre

l-rele

asin

g

intra

ute

rine s

yste

m

(LN

G-IU

S)2, 3

Tra

nexam

ic a

cid

(non-h

orm

onal)

Can b

e u

sed in

para

llel w

ith

investig

atio

ns. If n

o

impro

vem

ent s

top tre

atm

ent

afte

r 3 c

ycle

s

Non-s

tero

idal a

nti-in

flam

mato

ry

dru

gs (N

SA

IDs)

(non-h

orm

onal)

Can b

e u

sed in

para

llel w

ith

investig

atio

ns. If n

o

impro

vem

ent s

top tre

atm

ent

afte

r 3 c

ycle

s

Pre

ferre

d o

ver tra

nexam

ic a

cid

in d

ysm

enorrh

oea

Com

bin

ed o

ral c

ontra

ceptiv

es

3

Ora

l pro

gesto

gen

(nore

this

tero

ne)3

Inje

cte

d p

rogesto

gen

2, 3

Gonadtro

phin

-rele

asin

g

horm

one (G

n-R

H a

nalo

gue)

If used fo

r more

than 6

month

s

add-b

ack H

RT

thera

py is

recom

mended

A d

evic

e w

hic

h s

low

ly re

leases p

rogesto

gen

and p

revents

pro

lifera

tion o

f the e

ndom

etriu

m

A p

hysic

al e

xam

inatio

n is

needed b

efo

re

fitting

Ora

l antifib

ronoly

ctic

table

ts

Ora

l table

ts th

at re

duce p

roductio

n o

f

pro

sta

gla

ndin

Ora

l table

ts th

at p

revent p

rolife

ratio

n o

f the

endom

etriu

m

Ora

l table

ts th

at p

revent p

rolife

ratio

n o

f the

endom

etriu

m

Intra

muscula

r inje

ctio

n th

at p

revents

pro

lifera

tion o

f the e

ndom

etriu

m

Inje

ctio

n th

at s

tops p

roductio

n o

f oestro

gen

and p

rogeste

rone

Yes

No

No

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Co

mm

on

: Irregula

r ble

edin

g th

at m

ay la

st fo

r over 6

month

s; h

orm

one

rela

ted p

roble

ms s

uch a

s b

reast te

ndern

ess, a

cne o

r headaches (if p

resent)

are

min

or a

nd tra

nsito

ry. L

ess c

om

mo

n: A

menorrh

oea

Ra

re: U

terin

e p

erfo

ratio

n a

t time o

f insertio

n

Less c

om

mo

n: In

dig

estio

n; d

iarrh

oea; h

eadache

Co

mm

on

: Indig

estio

n; d

iarrh

oea

Ra

re: W

ors

enin

g o

f asth

ma in

sensitiv

e in

div

duals

; peptic

ulc

er w

ith

possib

le b

leedin

g a

nd p

erito

nitis

Co

mm

on

: Mood c

hange; h

eadache; n

ausea; flu

id re

tentio

n; b

reast

tendern

ess

Very

Ra

re: D

VT; s

troke; h

eart a

ttack

Co

mm

on

: Weig

ht g

ain

; blo

atin

g; b

reast te

ndern

ess; h

eadaches; a

cne

(usually

min

or o

r transie

nt)

Ra

re: D

epre

ssio

n

Co

mm

on

: Weig

ht g

ain

; irregula

r ble

edin

g; a

menorrh

oea; p

rem

enstru

al-lik

e

syndro

me (b

loatin

g,b

reast te

ndern

ess, flu

id re

tentio

n)

Less c

om

mo

n: L

oss o

f bone d

ensity

Co

mm

on

: Menopausal-lik

e s

yndro

me (h

ot flu

shes, in

cre

ased s

weatin

g,

vagin

al d

ryness)

Less c

om

mo

n: O

ste

oporo

sis

, partic

ula

rly tra

becula

r bone w

ith u

se lo

nger

than 6

month

s

1 The e

vid

ence fo

r effe

ctiv

eness c

an b

e fo

und in

the fu

ll guid

elin

e

2 Check th

e S

um

mary

of P

roduct C

hara

cte

ristic

s fo

r curre

nt lic

enced in

dic

atio

ns. In

form

ed

co

nse

nt is

ne

ed

ed

wh

en

usin

g o

uts

ide

lice

nse

d in

dic

atio

ns

3 See W

HO

‘Pharm

aceutic

al e

ligib

ility c

riteria

for c

ontra

ceptiv

e u

se

’ (WH

OM

EC

), ww

w.ffp

rhc.o

rg.u

k/a

dm

in/u

plo

ads/2

98_200506.p

df

4 Co

mm

on

: 1 in

10

0 c

ha

nce

; less c

om

mo

n: 1

in 1

00

0 c

ha

nce

; rare

: 1 in

10

,00

0 c

ha

nce

; ve

ry ra

re: 1

in 1

00

,00

0 c

ha

nce

Ho

w it w

ork

s

Contracep

tive? Impact

on fertility?

Po

ten

tial u

nw

an

ted

ou

tco

mes

exp

erie

nced

by s

om

e w

om

en

t4


Table 2 Surgical and radiological treatment options for women whosequality of life is severely impacted

Provide information to the woman before her outpatient appointment.

Continued overleaf

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rma

l

First

ge

ne

ratio

n

�ro

llerb

all

�tr

an

sce

rvic

al

rese

ctio

n o

f

en

do

me

triu

m

Ute

rin

e a

rte

ry

em

bo

lisa

tio

n

(UA

E)

Hyste

rosco

pic

myo

me

cto

my

De

str

oys t

he

wo

mb

lin

ing

Sm

all

pa

rtic

les a

re

inje

cte

d in

to t

he

blo

od

ve

sse

ls t

ha

t

take

blo

od

to

th

e

ute

rus.

Th

e b

loo

d

su

pp

ly t

o t

he

fib

roid

s is b

locke

d,

ca

usin

g t

he

m t

o

sh

rin

k

Su

rgic

al re

mo

va

l

of

the

fib

roid

s

usin

g a

hyste

rosco

pe

Yes

Fe

rtili

ty is

po

ten

tia

lly

reta

ine

d

Fe

rtili

ty is

po

ten

tia

lly

reta

ine

d

Oth

er

co

ns

ide

rati

on

s

Dis

cu

ss im

pa

ct

on

fe

rtili

ty

Use

se

co

nd

ge

ne

ratio

n

tech

niq

ue

in

wo

me

n w

ith

no

str

uctu

ral o

r h

isto

log

ica

l

ab

no

rma

lity

Ad

vis

e u

se

of

effe

ctive

co

ntr

ace

ptio

n f

ollo

win

g t

his

pro

ce

du

re

Dis

cu

ss im

pa

ct

on

fe

rtili

ty

Dis

cu

ss im

pa

ct

on

fe

rtili

ty

Co

nsid

er

pre

tre

atm

en

t w

ith

Gn

-RH

an

alo

gu

e

Fo

llow

ing

with

a f

irst

ge

ne

ratio

n a

bla

tio

n t

ech

niq

ue

is a

pp

rop

ria

te

Co

mm

on

: V

ag

ina

l d

isch

arg

e;

incre

ase

d p

erio

d

pa

in o

r cra

mp

ing

(e

ve

n if

no

fu

rth

er

ble

ed

ing

);

ne

ed

fo

r a

dd

itio

na

l su

rge

ry

Le

ss

co

mm

on

: In

fectio

n

Ra

re:

pe

rfo

ratio

n (

ve

ry r

are

with

se

co

nd

ge

ne

ratio

n t

ech

niq

ue

s.

Co

mm

on

: P

ers

ise

nt

va

gin

al d

isch

arg

e;

po

st-

em

bo

lisa

tio

n s

yn

dro

me

(p

ain

, n

au

se

a,

vo

mitin

g,

feve

r –

no

t in

vo

lvin

g h

osp

ita

lisa

tio

n)

Le

ss

co

mm

on

: N

ee

d f

or

ad

ditio

na

l su

rge

ry;

pre

ma

ture

ova

ria

n f

ailu

re p

art

icu

larly in

wo

me

n

>4

5;

ha

em

ato

ma

Ra

re:

Ha

em

orr

ha

ge

; n

on

-ta

rge

t e

mb

olis

atio

n

ca

usin

g t

issu

e n

ecro

sis

; in

fectio

n c

au

sin

g

se

ptica

em

ia

Le

ss

co

mm

on

: A

dh

esio

ns (

wh

ich

ma

y le

ad

to

pa

in a

nd

/or

imp

aire

d f

ert

ility

); n

ee

d f

or

ad

ditio

na

l

su

rge

ry;

pe

rfo

ratio

n;

recu

rre

nce

of

fib

roid

s;

infe

ctio

n

Ra

re:

Ha

em

orr

ha

ge


Table 2 (cont) Surgical and radiological treatment options forwomen whose quality of life is severely impacted

Provide information to the woman before her outpatient appointment.Typ

e o

f su

rgery

Fib

roid

s (>

3cm

dia

mete

r) +

Severe

impact o

n

quality

of life

Fib

roid

s (>

3cm

dia

mete

r) +

Severe

impact o

n

quality

of life

Not firs

t line,

sole

ly fo

r HM

B.

Consid

er w

hen:

�O

ther

treatm

ents

have

fa

iled,

contra

indic

ate

d

or d

eclin

ed

�D

esire

for

am

enorrh

oea

�F

ully

info

rmed

w

om

an

re

quests

it

�N

o d

esire

to

reta

in u

teru

s o

r

fe

rtility

5 Co

mm

on

: 1 in

100 c

hance; le

ss c

om

mo

n: 1

in 1

000 c

hance; ra

re: 1

in 1

0,0

00

ch

an

ce

; ve

ry ra

re: 1

in 1

00

,00

0 c

ha

nce

Ho

w it w

ork

s

Imp

act

on

futu

re

fertility

?

Po

ten

tial u

nw

an

ted

ou

tco

mes

exp

erie

nced

by s

om

e w

om

en

t5

Ind

icatio

n

Myom

ecto

my

Hyste

recto

my

Decid

e ro

ute

based o

n

indiv

idual

assessm

ent

Firs

t line: v

agin

al

Second lin

e:

abdom

inal

Do n

ot re

move

health

y o

varie

s

Hyste

recto

my

Decid

e ro

ute

based o

n

indiv

idual

assessm

ent

Firs

t line: v

agin

al

Second lin

e:

abdom

inal

Consid

er

laparo

scopic

vagin

al

hyste

recto

my in

mo

rbid

ly o

be

se

/

oophore

cto

my

Do n

ot re

move

health

y o

varie

s

Surg

ical re

moval

of th

e fib

roid

s

Surg

ical re

moval

of th

e u

teru

s

Ovarie

s m

ay a

lso

be re

moved

(oophore

cto

my)

Surg

ical re

moval

of th

e u

teru

s

Ovarie

s m

ay a

lso

be re

moved

(oophore

cto

my)

Fertility

is

pote

ntia

lly

reta

ined

Yes

Yes

Oth

er c

on

sid

era

tion

s

Dis

cuss im

pact o

n fe

rtility

Consid

er p

retre

atm

ent w

ith

Gn

-RH

an

alo

gu

e

Dis

cuss im

pact o

n s

exual

feelin

gs, fe

rtility, bla

dder

functio

n, p

sycholo

gy

Dis

cuss c

om

plic

atio

ns,

expecta

tions, a

ltern

ativ

es

Consid

er p

retre

atm

ent w

ith

Gn

-RH

an

alo

gu

e

Dis

cuss in

cre

ased ris

k in

wom

en w

ith fib

roid

s

Dis

cuss to

tal a

nd s

ubto

tal

meth

ods in

abdom

inal s

ur g

ery

If consid

erin

g o

ophore

cto

my,

dis

cuss im

pact o

n w

ellb

ein

g

If concern

ed d

iscuss ris

ks a

nd

benefits

with

wom

an. o

ffer

genetic

counsellin

g

Dis

cuss im

pact o

n s

exual

feelin

gs, fe

rtility, bla

dder

functio

n, p

sycholo

gy

Dis

cuss c

om

plic

atio

ns,

expecta

tions, a

ltern

ativ

es

Consid

er p

retre

atm

ent w

ith

Gn

-RH

an

alo

gu

e

Dis

cuss in

cre

ased ris

k in

wom

en w

ith fib

roid

s

Dis

cuss to

tal a

nd s

ubto

tal

meth

ods in

abdom

inal s

urg

ery

If consid

erin

g o

ophore

cto

my,

dis

cuss im

pact o

n w

ellb

ein

g

If concern

ed d

iscuss ris

ks a

nd

benefits

with

wom

an. o

ffer

genetic

counsellin

g

Less c

om

mo

n: V

agin

al d

ischarg

e; in

cre

ased

perio

d p

ain

or c

ram

pin

g (e

ven if n

o fu

rther

ble

edin

g); n

eed fo

r additio

nal s

urg

ery

; recurre

nce

of fib

roid

s; in

fectio

n.

Ra

re: H

ae

mo

rrha

ge

Co

mm

on

: Infe

ctio

n

Less c

om

mo

n: In

traopera

tive h

aem

orrh

age;

dam

age to

oth

er a

bdom

inal o

rgans e

g u

rinary

tract o

r bow

el; u

rinary

tract d

ysfu

nctio

n –

frequent

passin

g o

f urin

e o

r incontin

ence

Ra

re: T

hro

mbosis

(DV

T a

nd c

lot o

n lu

ng

Ve

ry ra

re: D

eath

With oophorectom

y at time of hysterectom

yC

om

mo

n: M

en

op

au

sa

l-like

su

mp

tom

s

Co

mm

on

: Infe

ctio

n

Less c

om

mo

n: In

traopera

tive h

aem

orrh

age;

dam

age to

oth

er a

bdom

inal o

rgans e

g u

rinary

tract o

r bow

el; u

rinary

tract d

ysfu

nctio

n –

frequent

passin

g o

f urin

e o

r incontin

ence

Ra

re: T

hro

mbosis

(DV

T a

nd c

lot o

n lu

ng

Ve

ry ra

re: D

eath

With oophorectom

y at time of hysterectom

yC

om

mo

n: M

en

op

au

sa

l-like

su

mp

tom

s

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