Local Policy Statement No 12 POLICY STATEMENT TITLE/TOPIC: Specific Obstetric and Gynaecology procedures ISSUE DATE: November 2011 1) INSERTION AND REMOVAL OF INTRA UTERINE CONTRACEPTIVE DEVICES (IUCD) DEFINITION An IUCD is a birth control device that is placed in the uterus by a doctor. Although they can come in different shapes and sizes, IUCDs are generally about 1 1/2 inches long, in the shape of a T, and have a copper coating. IUCDs have strings that extend from the device in the uterus, through the cervix and into the vagina. They can be felt to ensure that the IUCD is still in place, but they cannot be seen outside of the body There are two types of IUCDs: those that release progestin and those that do not. COMMISSIONING RECOMMENDATION: The insertion and removal of any IUCD should only be undertaken in a primary care setting, it is not commissioned as a secondary care service RISKS IUCDs do not protect against sexually transmitted diseases (STDs). Women who get an STD while using an IUCD are also more likely to develop pelvic inflammatory disease (PID). In 2 percent to 10 percent of cases, the uterus will push the IUCD out of the body. Fever and chills are other side effects. IUCDs cause cramps and backaches in some women. Heavier bleeding than normal and spotting are also common side effects, though this usually only lasts for the first few months. There is a greater risk of having an ectopic pregnancy with an IUCD than without one. 2) VAGINAL PESSARIES DEFINITION A vaginal pessary is a plastic device that fits into the vagina to help support the uterus (womb), vagina, bladder or rectum. 1 Version 1.0 prepared by Dr Sheila Will July 2011 Adopted November 2011 due for review November 2012 The pessary is most often used for prolapse of the uterus. Prolapse means that the uterus droops or sags into the vaginal canal because the muscles and ligaments that should support it are weak. This may occur after childbirth or pelvic surgery. Prolapse of the uterus is usually fixed with surgery but a vaginal pessary can be used to help keep the uterus in place. A pessary can also be used for a cystocele (when the bladder droops down into the vagina) or for a rectocele (when the wall of the rectum bulges into the bottom of the vagina). A pessary can also help many women who have stress urinary incontinence (the leaking of urine when you cough, strain or exercise). Pregnant women who have incontinence can also use a vaginal pessary. COMMISSIONING RECOMMENDATION: The insertion of vaginal pessaries should only be undertaken in a primary care setting, it is not commissioned as a secondary care service SIDE EFFECTS: Vaginal irritation and discharge 3) HYSTEROSCOPY DEFINITION A hysteroscopy is a procedure used to examine the inside of the uterus (womb). It is done using a hysteroscope, a narrow tube with a telescope at the end. Images are sent to a computer to give a close-up of the uterus A diagnostic hysteroscopy is used to look for abnormalities in the womb and find the cause of any symptoms. These can include: heavy or irregular periods pelvic pain unusual vaginal discharge repeated miscarriage infertility It can be performed with or without a local anaesthetic that numbs the area around the womb. 2 Version 1.0 prepared by Dr Sheila Will July 2011 Adopted November 2011 due for review November 2012 Operative hysteroscopy A hysteroscopy is described as operative when it involves an additional procedure such as a biopsy or treatment. If an abnormality is suspected when viewing the inside of the uterus a biopsy (a small sample of tissue) may be taken to be examined. If a medical condition is diagnosed straight away, such as a polyp (a projecting mass of overgrown tissue), it may be treated during the hysteroscopy. The most common treatments carried out during a hysteroscopy include the removal of: polyps adhesions and scar tissue in the womb fibroids (non-cancerous growths) in the womb a lost or stuck contraceptive device A contraceptive device can also be fitted during hysteroscopy. COMMISSIONING RECOMMENDATION: When appropriate, outpatient rather than inpatient ambulatory hysteroscopy will be considered CONTRAINDICATED Hysteroscopy is contraindicated during pregnancy or where the patient has a vaginal or urinary tract infection or a cancer of the womb. 4) DIAGNOSTIC DILATATION AND CURETTAGE FOR WOMEN UNDER 40 YEARS DEFINITION Dilatation and curettage (D&C) is a procedure where tissue is removed from the endometrium (the lining of the womb (uterus) (by dilating the cervix (Dilatation) and scraping out the lining of the womb (Curettage)). COMMISSIONING RECOMMENDATION: Effective Health Care Bulletin 9 recommended that diagnostic D&C should not be performed routinely on women aged under 40 since the risks of anaesthesia, uterine perforation and cervical laceration outweigh the minimal potential benefit. Newer methods of endometrial sampling appear to be at least as accurate as D&C with high levels of acceptability and lower complication rates. For women 3 Version 1.0 prepared by Dr Sheila Will July 2011 Adopted November 2011 due for review November 2012 with dysfunctional uterine bleeding, a range of medical interventions is available (e.g. mefenamic acid with norethisterone etc). In the investigation of dysfunctional uterine bleeding, hysteroscopy with selected biopsy and curettage is preferable. D&C alone should not be used as a diagnostic tool or as a therapeutic treatment. If appropriate, a biopsy should be taken to exclude endometrial cancer or atypical hyperplasia. Indications for a biopsy include persistent inter-menstrual bleeding, and in women aged 45 and over treatment failure or ineffective treatment. Ultrasound is the first line diagnostic tool for identifying structural abnormalities. Hysteroscopy should be used as a diagnostic tool only when ultrasound results are inconclusive, for example, to determine the exact location of a fibroid or the exact nature of the abnormality. NICE Guidance CG44 5) HYSTERECTOMY (ABDOMINAL AND VAGINAL) DEFINITION Hysterectomy is an operation to remove the uterus (womb). A hysterectomy is used to treat conditions that affect the female reproductive system. A hysterectomy is a major operation with a long recovery time. It is usually only considered after alternative, less invasive treatments have been tried. Types of hysterectomy Total hysterectomy: this is the most commonly performed operation. The uterus and cervix (neck of the womb) are removed. Subtotal hysterectomy: the main body of the uterus is removed leaving the cervix in place. Total hysterectomy with bilateral salpingo-oophorectomy: the uterus, cervix, fallopian tubes (salpingectomy) and the ovaries (oophorectomy) are removed. Radical hysterectomy: the uterus and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue. 4 Version 1.0 prepared by Dr Sheila Will July 2011 Adopted November 2011 due for review November 2012 There are three ways to perform a hysterectomy: Vaginal hysterectomy: the uterus is removed through a cut in the top of the vagina. Abdominal hysterectomy: the uterus is removed through a cut in the lower abdomen. Laparoscopic hysterectomy (keyhole surgery): the uterus is removed through a number of small cuts in the abdomen. COMMISSIONING RECOMMENDATION: Hysterectomy should not be used as a first-line treatment solely for heavy menstrual bleeding. Hysterectomy should only be undertaken if patients have followed the Map of Medicine pathway, or are on a cancer referral pathway See NICE Guidance CG44 6 Version 1.0 prepared by Dr Sheila Will July 2011 Adopted November 2011 due for review November 2012 .