TNRF2: Gynaecology

Overview

Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping.

Thresholds and eligibility 

NHS Surrey Heartlands will fund dilation and curettage for diagnostic purposes for suspected malignancy and for evacuation of retained products of conception.

NICE Guideline 44 Heavy Menstrual Bleeding states that dilation and curettage is not recommended alone as a diagnostic tool or as a therapeutic treatment for heavy menstrual bleeding. Vacuum aspiration is the preferred treatment for removing retained products of conception. Dilation and curettage for the investigation of abnormal uterine bleeding is appropriate in the following circumstances:

• Transvaginal ultrasound with Pipelle endometrial aspirate has failed due to cervical stenosis or pain and facilities for a hysteroscopy with targeted biopsy are unavailable.

OR 

• Hysteroscopy with targeted biopsy has failed/is not possible due to cervical stenosis, pain, or inability to dilate the cervix.

OR 

• Transvaginal ultrasound has demonstrated focal pathology and facilities for a hysteroscopy with targeted biopsy are unavailable. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Pelvic organ prolapse is when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. It can be the womb (uterus), bowel, bladder or top of the vagina.  The aim of surgery is to restore support of the prolapsing organ and remove the bulge sensation.

Thresholds and eligibility 

This procedure is not routinely funded for asymptomatic or mild pelvic organ prolapse. 

Referral for specialist assessment with the option of surgical treatment is indicated for: 

• Patients with grade 1-2 POP whose symptoms have not improved with conservative management. This could include:
  • lifestyle modification (losing weight, minimising heavy lifting, preventing/treating constipation)
  • supervised pelvic floor muscle training for at least 16 weeks 
  • topical oestrogen
  • pessary fitting.

OR

• Patients with grade 1-2 POP combined with urethral sphincter incompetence or faecal incontinence.

OR  

• Patients with moderate to severe symptoms of prolapse (for example, grade 3-4, or including urethral sphincter incompetence or faecal incontinence), where conservative management has not improved symptoms, is not appropriate (for example, due to cognitive impairment) or has been declined by the patient.

Providers are strongly encouraged to ensure shared decision making takes place with women considering surgery for POP.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Female sterilisation is an operation to permanently prevent pregnancy. The fallopian tubes are blocked or sealed to prevent the eggs reaching the sperm and becoming fertilised.

Thresholds and eligibility 

Sterilisation will not be available on non-medical grounds unless the woman has had at least 12 months' trial using Mirena or Implanon and found it unsuitable.

NHS Surrey Heartlands will fund this procedure: 

• Where sterilisation is to take place at the time of another procedure such as caesarean section.

OR 

• Where there is a clinical contraindication to the use of a Mirena/Implanon.

OR

• Where there are severe side effects with the use of Mirena/Implanon.

 
OR 

• Where there is an absolute clinical contraindication to pregnancy.  These are: 
  • Young women (under 45 years of age) undergoing endometrial ablation for heavy periods 
  • Women with severe diabetes
  • Women with severe heart disease

AND

• Women should be informed that vasectomy carries a lower failure rate in terms of post-procedure pregnancies and that there is less risk related to the procedure. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Hysterectomy as a treatment option for heavy menstrual bleeding is an invasive procedure which has to be reserved for women for whom other treatment options have failed or are contra-indicated. 

Thresholds and eligibility 

Based on NICE guidance [NG88] Heavy menstrual bleeding: assessment and management, hysterectomy should not be used as a first-line treatment solely for heavy menstrual bleeding (HMB).

It is important that healthcare professionals understand what matters most to each individual and support their personal priorities and choices.

Hysterectomy should be considered only when: other treatment options have failed, are contradicted; there is a wish for amenorrhoea (no periods); the individual (who has been fully informed) requests it; the individual no longer wishes to retain their uterus and fertility.

Management of HMB

NICE guidelines section 1.5.1 states: when agreeing treatment options for HMB with women, take into account: the woman’s preferences, any comorbidities, the presence, or absence of fibroids (including size, number, and location), polyps, endometrial pathology or adenomyosis, other symptoms such as pressure and pain.

Treatments for women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis

Section 1.5.2 states: consider an LNG-IUS (levonorgestrel-releasing intrauterine system) as the first treatment for HMB in women with: no identified pathology or fibroids less than 3 cm in diameter, which are not causing distortion of the uterine cavity or suspected or diagnosed adenomyosis.

Section 1.5.3 states: if a woman with HMB declines an LNG-IUS or it is not suitable, consider the following pharmacological treatments: non-hormonal: tranexamic acid, NSAIDs (non-steroidal anti-inflammatory drugs), hormonal: combined hormonal contraception, cyclical oral progestogens.

Section 1.5.4 states: be aware that progestogen-only contraception may suppress menstruation, which could be beneficial to women with HMB.

Section 1.5.5 states: if treatment is unsuccessful, the woman declines pharmacological treatment, or symptoms are severe, consider referral to specialist care for: investigations to diagnose the cause of HMB, if needed, taking into account any investigations the woman has already had and alternative treatment choices, including: pharmacological options not already tried (see recommendations 1.5.2 and 1.5.3), surgical options: second-generation endometrial ablation, hysterectomy.

Section 1.5.10 states: for women with submucosal fibroids, consider hysteroscopic removal.

Treatments for women with fibroids of 3 cm or more in diameter.

Section 1.5.7 states: consider referring women to specialist care to undertake additional investigations and discuss treatment options for fibroids of 3 cm or more in diameter.

Section 1.5.8 states: if pharmacological treatment is needed while investigations and definitive treatment are being organised, offer tranexamic acid and/or NSAIDs.

Section 1.5.9 states: advise women to continue using NSAIDs and/or tranexamic acid for as long as they are found to be beneficial.

Section 1.5.10 states: for women with fibroids of 3 cm or more in diameter, take into account the size, location and number of fibroids, and the severity of the symptoms and consider the following treatments: Pharmacological: non-hormonal: tranexamic acid, NSAIDs, hormonal: LNG-IUS, combined hormonal contraception, cyclical oral progestogens, uterine artery embolization, surgical: myomectomy, hysterectomy.

Section 1.5.12 states: be aware that the effectiveness of pharmacological treatments for HMB may be limited in women with fibroids that are substantially greater than 3 cm in diameter.

Section 1.5.13 states: prior to scheduling of uterine artery embolisation or myomectomy, the woman’s uterus and fibroid(s) should be assessed by ultrasound. If further information about fibroid position, size, number, and vascularity is needed, MRI should be considered.

Section 1.5.14 states: consider second-generation endometrial ablation as a treatment option for women with HMB and fibroids of 3 cm or more in diameter who meet the criteria specified in the manufacturers’ instructions.

Section 1.5.15 states: if treatment is unsuccessful: consider further investigations to reassess the cause of HMB, taking into account the results of previous investigations and offer alternative treatment with a choice of the options described in recommendation 5.10.

Section 1.5.16 states: pretreatment with a gonadotrophin-releasing hormone analogue before hysterectomy and myomectomy should be considered if uterine fibroids are causing an enlarged or distorted uterus.

For further information, please see:

• NICE Guidance [NG 88] Heavy menstrual bleeding: assessment and management
• NHS Conditions: Heavy periods

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

A labiaplasty is surgery to reduce the size of the labia minora – the flaps of skin either side of the vaginal opening.

Thresholds and eligibility 

NHS Surrey Heartlands will only consider commissioning labiaplasty where medically necessary and secondary to another underlying medical condition:

• Where the labia are directly contributing to recurrent disease or infection (this could include ulceration/maceration).

OR

• Cancer

OR

• Where the repair of the labia is required after significant trauma (including during childbirth).

Surgery will only be considered for adults aged 18 or over (unless medically indicated, e.g., cancer, in under 18s) due to changes in the patient’s body during puberty.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Uterine fibroid embolization is a minimally-invasive alternative to hysterectomy or myomectomy.

Performed instead of major surgery, this procedure requires minimal or no hospital stay and a shorter recovery. In this procedure, blood supply to the fibroid tumours is blocked, making them shrink.

Thresholds and eligibility 

Uterine fibroid embolization may be considered for the treatment of symptomatic large (>3cm) or multiple fibroids and offered as a one-off treatment when:

• The patient is symptomatic. 

AND

• Conservative management at first and second line (including but not limited to; gonadotropin releasing hormone analogues (GnRHas), non-steroidal anti-inflammatory drugs (NSAIDs), hormone replacement therapy (HRT), Levonorgestrel intrauterine system (LNG-IUS), tranexamic acid, other appropriate contraceptives, Ulipristal acetate if clinically appropriate, has been unsuccessful.

AND

• Women of child-bearing age who wish, or might wish, to become pregnant in the future should only be offered the intervention after fully informed discussion about potential risks to fertility and should be considered on a case-by-case basis.

This procedure should only be carried out by radiologists with the appropriate training and competence.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.