Delivering an effective outpatient service in gynaecology: an assessment of patient preference

Diagnostic hysteroscopy and saline infusion sonography in the diagnosis of intrauterine abnormalities: an assessment of patient preference

This study was conducted to assess whether women would prefer to undergo saline infusion sonography (SIS) or office hysteroscopy for the investigation of the uterine cavity. In a randomised controlled trial, 100 patients underwent SIS or office hysteroscopy for assessing patients' pain scores. After the investigation, 92 of them were asked to fill out an anonymous questionnaire addressing their preference regarding the method of evaluation and treatment of the uterine cavity. A control group, consisting of 50 women who never underwent SIS or office hysteroscopy, was also asked to complete an identical questionnaire. The questionnaire was completed by 113 women (83.7%). Twenty-four (21.2%) women would opt for SIS, whereas 52 (46.0%) would opt for office hysteroscopy, and 37 (32.7%) had no preference. If therapy would be necessary, 48.7% of the women would opt for an outpatient treatment, whereas 33.0% of the women would prefer treatment under general anaesthesia. Despite the fact that SIS is less painful, the majority of the women prefer office hysteroscopy. Additionally, therapy in an outpatient setting is preferred to a day case setting.

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis

BACKGROUND

This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

SEARCH STRATEGY

Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.

SETTING

University Hospital.

SELECTION CRITERIA

The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.

DATA COLLECTION AND ANALYSIS

Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.

MAIN RESULTS

One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pre-test probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).

CONCLUSIONS

This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

OBJECTIVE

To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery.

DESIGN

A randomised controlled trial.

SETTING

A large UK Teaching hospital.

POPULATION

Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal.

METHODS

The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic.

MAIN OUTCOME MEASURES

The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy.

RESULTS

The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal.

CONCLUSION

Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.

Standard setting for outpatient gynaecology procedures: A multidisciplinary framework for implementation

This chapter describes the changing cultural background of health care from which any service is delivered. In particular, the authors hope to outline cultural, educational, technical and environmental changes that have been used as opportunities to develop a quality-assessed outpatient hysteroscopic service. Examined within the chapter will be the roles and limitations of evaluation and audit, research and the multidisciplinary team. The importance of process, relationships and collaborative working within organizations will be explored, and outpatient hysteroscopy will be used as a working example of how these inform a model of practice development.

Thermachoice endometrial ablation in the outpatient setting, without local anesthesia or intravenous sedation: A prospective cohort study

OBJECTIVE

To determine whether Thermachoice endometrial ablation (EA) is a safe and acceptable procedure when performed in the outpatient (OP) setting without local anesthesia or IV sedation.

DESIGN

Prospective cohort (double group) study.

SETTING

Hysteroscopy clinic of large UK hospital.

PATIENT(S)

Twenty-seven women with menorrhagia.

INTERVENTION(S)

The first cohort of women underwent Thermachoice EA without elective analgesia. The second cohort underwent Thermachoice after taking ibuprofen.

MAIN OUTCOME MEASURE(S)

To map pain scores and the requirement of "rescue analgesia." To assess speed of recovery and time away from home.

RESULT(S)

Thermachoice EA was successfully performed in the OP setting on 89% (n = 24) of women. Four women in the first cohort required rescue analgesia compared to none in the second. During the procedure there was little difference between the groups visual analogue style pain scores-with the overall score being 3.6 (range = 0-10). Postoperatively there was a lower mean pain score in the second cohort, with fewer women experiencing nausea and vomiting. Mean time away from home was 2.6 hours and mean time to make a full recovery was 3.3 days. Women required analgesia for 2.6 days, on average, and returned to their normal activities at this time.

CONCLUSION(S)

Thermachoice EA without local analgesia or IV sedation can be safely and successfully performed in the OP setting and if ibuprofen is taken preoperatively few women require "rescue analgesia."

The technique and overview of flexible hysteroscopy

Flexible hysteroscopy is a safe, successful, and reliable method of investigation for abnormal uterine bleeding. When compared with rigid hysteroscopy flexible hysteroscopy is associated with less pain both at introduction of the hysteroscope and during the procedure itself especially when the diameter of the scope is reduced. This article provides evidence of the benefits of flexible hysteroscopy to the health service provider, clinician, and patient. Flexible hysteroscopy is acceptable to most women when performed in the outpatient setting without analgesia and offers a suitable alternative to rigid hysteroscopy.