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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.

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 with mild symptoms whose symptoms persist despite conservative management, which may include:
  • Lifestyle modification (e.g. weight loss, avoiding heavy lifting, treating constipation)
  • Supervised pelvic floor muscle training (minimum 16 weeks)
  • Topical oestrogen
  • Pessary fitting

OR

• Patients with grade 1-2 POP with moderate to severe symptoms (e.g. associated urethral sphincter incompetence or faecal incontinence) or grade 3-4 POP, where conservative management:
  • Has failed, or
  • Is clinically inappropriate (e.g. due to cognitive impairment), or
  • Has been declined by the patient following informed discussion.

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

Resources

Treatments not routinely published policy (TNRF2)

Additional information

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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.

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 

The South East Regional Priorities Committee (SERPC) considered national guidance, the evidence base, baseline position, other integrated care board (ICB) policies, the views of clinical specialists, equality and equity issues, and the potential impact of changing policy. 

• All decisions were made with reference to the South East Region Policy Recommendation Committees’ Ethical Framework. Taking these into account, the SERPC recommends:
  • Female sterilisation will only be funded where criteria below is met, and fully informed consent has been obtained and recorded;
  • The individual has undergone an appropriate therapeutic trial of Long Acting Reversible Contraception (LARC)

OR

• • LARC is contra-indicated or inappropriate

Guidance and best practice points

• A consent form and clinical record should be used to document an individual’s agreement to the procedure, discussion that took place, requests made by the individual, and any information provided.
• If tubal occlusion is performed at the same time as a caesarean section, counselling and agreement should be given at least 2 weeks in advance of the procedure.
• A consent form for clinicians in obtaining consent of women undergoing sterilisation by laparoscopy or hysteroscopy or at the time of caesarean section can be found here (GIRFT& RCOG). Please also refer to the advice and guidance detailed in the FSRH Clinical Guidance: Male and Female Sterilisation.
• If a trial of LARC is deemed not to be of benefit to the individual (for example persistent side effects) the trial may be ended based on clinical judgment.
• All treatment and care should take into account women's individual needs and preferences.

South East region ICBs will always consider appropriate individual funding requests (IFRs) through their IFR processes. Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.

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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.

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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.

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

However, if the patient does not meet the criteria, and their clinician is able to demonstrate that their patient’s individual clinical circumstances are clearly different to those of other patients, they have the option of submitting an Individual Funding Request (IFR) application to Surrey Heartlands ICB via the Blueteq database.

Simply put, the consideration is whether it is fair to fund their patient’s treatment when the treatment is not available to others.