Obstetrics and Gynaecology

Audit of 2-week wait referrals to the Gynecology Department in District General Hospital and investigating patient awareness of the reasons and importance behind the referral (2018)

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Type of publication:
Conference abstract

Author(s):
Wilkinson M.; *Sahu B

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; Dec 2018; vol. 125 ; p. 48

Abstract:
Introduction Two-week wait referrals to gynecology services are at a premium with pressure on numbers. Referrals can be inappropriate. Patients are often unaware the appointment is for suspected cancer. Methods Two-week wait referrals were examined during a six month period. The gynecologist in clinic collected data. Patients were asked about their 2-week wait referral, gauging awareness around their referral. Clinical symptoms and signs were compared to those in referral. Appropriateness of the referral was assessed by symptoms fitting the 2-week wait criteria or clinical findings on referral not consistent with the presenting symptoms and findings in clinic. Results A total of 172 patients were referred under the 2-week wait criteria; mean age was 58 years, range (17-95). Referrals were from 50 separate primary care practices. Suspected cancer referrals were composed of 111 endometrial, 15 ovarian, 22 cervical, 15 vulva/vaginal and 9 of mixed pathology. There was awareness of referral for cancer in 90 cases (52%), awareness of "2-week wait" in 124 cases (72%) and aware that the appointment could be at either hospital within the trust in 96 cases (56%). The referral was considered appropriate for 2-week wait referral in 123 (72%) of cases. Conclusion The majority of patients were referred correctly. A wide range of pathologies was seen. A significant number could have been referred as routine referrals or advice requested. Patient awareness of it being a referral due to suspected cancer was poor with better appreciation of the urgency of referral.

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A survey of management of vulvar disorders in the primary health care setting in an urban area of England (2018)

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Type of publication:
Journal article

Author(s):
*Kandanearachchi P.; *Sahu B.; *Antonakou A.; *Papoutsis D.

Citation:
Archives of Hellenic Medicine; 2018; vol. 35 (no. 3); p. 405-411

Abstract:
OBJECTIVE To determine the frequency of consultation for vulvar diseases in the primary health care setting, and their investigation and management patterns, and to identify the training needs of general practitioners (GPs) in vulvar disease. METHOD A survey was conducted using a 13-item questionnaire handed out to GPs during their regional post-graduate seminars in the area of Shropshire in the West Midlands in England. RESULTS Of 120 questionnaires distributed, a total of 107 responses were received (response rate: 89.1%). Of the participants, 67.3% reported that they see more than 5 patients per month with vulvar symptoms, and 24.6% that they see more than 5 patients per month with recurrent vulvar symptoms. The predominant symptom was pruritus vulvae (77.5%), with 94.5% of practitioners considering lichen sclero-sus as the most likely diagnosis. For recurrent pruritus vulvae a gynecological referral was made in most cases (86%). In contrast, when there was vulvar pain, only few practitioners would refer the patient to a gynecologist (8.4%) or a dermatologist (17.3%). Only 41.1% of GPs had ever received any kind of training, with all (100%) agreeing that formal training in the diagnosis and management of vulvar diseases would benefit their care of their patients. CONCLUSIONS This survey showed that a substantial number of women consult their GP with vulvar symptoms. A variety of approaches were reported in the diagnosis and management of these cases. All the GPs agreed that there is a need for formal training in vulvar disease.

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The paediatrician and the management of common gynaecological conditions (2018)

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Type of publication:
Journal article

Author(s):
*Ritchie, Joanne K; Latthe, Pallavi; Jyothish, Deepthi; Blair, Joanne C

Citation:
Archives of disease in childhood; Jul 2018, 103(7), p. 703-706

Abstract:
Paediatric gynaecology is an emerging discipline. Since 2000, there has been an advanced training programme in paediatric gynaecology available for obstetric and gynaecology trainees; additionally, a set of clinical standards1 for the care of paediatric and adolescent patients has been developed by The British Society of Paediatric and Adolescent Gynaecology (BritSPAG). BritSPAG is a multidisciplinary group of professionals including gynaecologists, paediatricians, paediatric urologists and endocrinologists.Girls with gynaecological conditions are often seen in general paediatric services; it is important that those assessing them are confident in identifying patients who require more specialist care. Despite this, gynaecology does not appear in the Royal College of Paediatrics and Child Health curriculum. This article aims to increase the knowledge base and confidence of paediatricians in dealing with common paediatric and adolescent gynaecological conditions.

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Early and late pregnancy outcomes in women treated with cold-coagulation versus LLETZ cervical treatment for cervical intraepithelial neoplasia; a retrospective cohort study (2018)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios; *Underwood, Martyn ; *Parry-Smith, William; *Panikkar, Jane

Citation:
Archives of Gynecology and Obstetrics; Apr 2018; Vol.297(4):1015-1025

Abstract:
PURPOSE To compare the pregnancy outcomes between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia. METHODS This was a retrospective cohort study of women who had a single cervical treatment between 2010 and 2011. We identified those women who had a singleton pregnancy subsequent to their cervical treatment until September 2017. Women with previous cervical treatment, previous miscarriage or preterm delivery were excluded. RESULTSWe identified 86 women with a pregnancy after LLETZ treatment and 75 women after cold coagulation. Those who had LLETZ when compared to cold coagulation miscarried more often in the first trimester (33.7 vs 17.3%; p = 0.01) than in the second trimester. In women with LLETZ this effect of increased early miscarriage was shown to be prolonged and to persist up to 17 months after excision. Women with LLETZ when compared to cold coagulation had higher spontaneous preterm birth rates (8.9 vs 6.7%) even though the difference was non significant, with the earliest spontaneous preterm birth occurring at 32 weeks and 34 weeks, respectively. CONCLUSION We found that women who received LLETZ treatment when compared to cold coagulation had higher spontaneous preterm birth rates in their subsequent pregnancy and miscarried more frequently in the first trimester, and demonstrated an increased early miscarriage risk that persisted for more than a year after excisional treatment.

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The role of the myosure hysteroscopic tissue removal system in the office setting at detecting abnormal pathology in women with post-menopausal bleeding, who have had blind endometrial sampling reported as inadequate, inactive or benign endometrium (2017)

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Type of publication:
Conference abstract

Author(s):
*Underwood M. ; *Chadha R.; *Hudda A.; *Green J.; *Fry M.; *Barker V.

Citation:
Journal of Minimally Invasive Gynecology; 2017; vol. 24 (no. 7)

Abstract:
Study Objective: Identify any histological discrepancy between blind endometrial sampling (ES) reported as inadequate, inactive or benign endometrium and office based hysteroscopy with the MyoSure tissue removal system in women with post-menopausal bleeding (PMB). Design: retrospective review of cases from our PMB clinic. Setting:Women attending the PMB clinic who's ES is reported as benign, inactive or inadequate. MyoSure Lite or Classic devices were used for the removal of these lesions. Patients:Women with PMB having an endometrial polypectomy using the MyoSure tissue removal system. Intervention: The MyoSure Lite & Classic tissue removal systems were used to remove endometrial polyps in women with PMB who's ES was inactive, inadequate or benign. Histological comparison between the ES and MyoSure histology was made. Measurements and Main Results: 616 women underwent hysteroscopic evaluation for abnormal uterine 2017; 399 were post-menopausal of which 186 women (46.6%) had inactive endometrium, 82 women (20.6%) had inadequate, 109 (27.3%) had benign/polyp and 22 (5.5%) had simple hyperplasia or higher grade disease detected on the blind endometrial sampling prior to polypectomy. The MyoSure polypectomy of those women with "Proliferative/benign endometrium" demonstrated that 19.3% had higher grade disease (Simple, complex, complex with atypia or cancer) than the ES, for the "inactive group 10.8% had high grade disease and those with an inadequate ES 13.4% had higher grade disease. (Table presented) Endometrial thickness in the PMB group ranged from 1.5-45 mm with a mean of 10.6 mm. There were no reported complications in all 616 cases. Conclusion: This retrospective review of patients with inadequate, inactive or benign ES has demonstrated the significant benefit to patient of having the polyp removed simply without complication in the office setting using the MyoSure tissue removal system. Between 10.8-19.3% will have higher grade disease detected using the MyoSure device, which would have an impact on their medical management.

Does CIN2 Have the Same Aggressive Potential As CIN3? A Secondary Analysis of High-Grade Cytology Recurrence in Women Treated with Cold-Coagulation Cervical Treatment (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D.; *Underwood M .; *Parry-Smith W.; *Panikkar J.

Citation:
Geburtshilfe und Frauenheilkunde; Mar 2017; vol. 77 (no. 3); p. 284-289

Abstract:
Introduction To determine whether women with CIN2 versus CIN3 on pretreatment cervical punch biopsy have less high-grade cytology recurrence following cold-coagulation cervical treatment. Materials and Methods This was a retrospective study of women having had cold coagulation between 2001-2011 in our colposcopy unit. Women with previous cervical treatment were excluded. Results We identified 402 women with 260 (64.7?%) cases of CIN2 and 142 (35.3?%) cases of CIN3 on pretreatment cervical punch biopsy. In the total sample, the mean age of women was 27.5 years (SD = 4.9), 75.1?% were nulliparous and 36.6?% were smokers. Referral cytology and pretreatment colposcopic appearance were high-grade in 62.7?% and 57.1?%. The mean follow-up period was 2.8 years (SD = 2.1). Women with CIN2 on pretreatment cervical biopsy when compared to those with CIN3 had less frequently high-grade referral cytology and high-grade pretreatment colposcopic appearances, and had less pretreatment cervical biopsies taken. During the follow-up period, women with CIN2 on pretreatment cervical biopsy had less high-grade cytology recurrence when compared to those women with CIN3 (1.9 vs. 5.6?%, p = 0.046). Multiple stepwise Cox regression analysis showed that women with CIN3 on pretreatment cervical biopsy had 3.21 times greater hazard for high-grade cytology recurrence (HR = 3.21, 95?% CI: 1.05-9.89; p = 0.041) in comparison with CIN2 cases. Conclusion We found that women with CIN2 on pretreatment cervical punch biopsy had less high-grade cytology recurrence following cold-coagulation treatment in comparison to those with CIN3. This finding lends support to the theory that CIN2 even though a high-grade abnormality might not have the same aggressive potential as CIN3.

Comparison of cure rates in women treated with cold-coagulation versus LLETZ cervical treatment for CIN2-3 on pretreatment cervical punch biopsies: a retrospective cohort study (2017)

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Type of publication:
Journal article

Author(s):
*Papoutsis D, *Underwood M , *Parry-Smith W, *Panikkar J.

Citation:
Archives of Gynecology and Obstetrics. 2017 Apr;295(4):979-986

Abstract:
PURPOSE:
To compare the cure rates between women who were treated with cold-coagulation versus large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia grade 2 (CIN2) or 3 (CIN3) on pretreatment cervical punch biopsies.
METHODS:
This was a retrospective cohort study of women having had a single cervical treatment for CIN2 or CIN3 on pretreatment cervical punch biopsies between 2010 and 2011. The cure rates were defined as the absence of any dyskaryosis (mild/moderate/severe) on cytology tests during follow-up and were determined at 6 and 12 months after treatment.
RESULTS:
We identified 411 women having had cervical treatment with 178 cases of cold-coagulation and 233 cases of LLETZ. The cure rates at 6 months following cold-coagulation and LLETZ treatment were 91.6 versus 97.1% (p = 0.02), whereas at 12 months, they were 96.5 versus 97.3% (p = 0.76). Multivariable analysis showed that after adjusting for confounding factors, there was a fourfold higher cure rate with LLETZ in comparison with cold-coagulation at 6 months after treatment (adjusted OR 4.50, 95% CI 1.20-16.83; p = 0.026), with this difference disappearing at 12 months. The lower cure rates with cold-coagulation were due to its higher rates of mild dyskaryosis cytology tests at 6 months. The rates of moderate/severe dyskaryosis cytology tests were similar between the two treatment methods at 6 and 12 months.
CONCLUSION:
We found that women with CIN2 or CIN3 on pretreatment cervical punch biopsies, after adjusting for multiple confounding factors, had higher cure rates when treated with LLETZ versus cold-coagulation at 6 months, with this difference disappearing at 12 months.

A national colposcopy survey comparing destructive versus excisional treatment for CIN (2016)

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Type of publication:
Conference abstract

Author(s):
Parry-Smith W., *Papoutsis D., Parris D., *Panikkar J., Redman C., *Underwood M.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, June 2016, vol./is. 123/(99)

Abstract:
Introduction Women found to have high grade CIN should be offered either ablative treatment or large loop excision of the transformation zone with appropriate biopsy. Objective 1) To learn if a trial of ablative versus excisional treatment would be supported by fellow colposcopists in the UK 2) To investigate the current practice amongst colposcopists with regards to ablative treatment for high grade CIN 3) To gain an understanding of aspects of practice such as use of local anaesthetic during punch biopsies Methods An electronic questionnaire was sent to all registered colposcopists in the United Kingdom (total = 1677). Of these, 325 responded (19%). The study was granted ethical approval by the council of the British Society for Colposcopy and Cervical Pathology (BSCCP). Results The majority of colposcopists n = 248 (76%) felt that a study investigating the morbidity and Test of Cure outcomes comparing excisional and destructive treatments was needed. A reduced complication and morbidity rate would be the greatest factor to encourage colposcopists to use destructive treatments more often n = 250 (76.92%). If a destructive treatment were found to have a significantly reduced complication, morbidity, and equal or higher patient satisfaction rate during the procedure, but resulted in a slightly higher need for further treatment 5%, this was acceptable to n = 140 (43.1%) of those surveyed. However, a further treatment rate of 2.5% was acceptable to n = 196 (60.1%). The majority n = 182 (56%) of colposcopists did not perform destructive treatments for high grade disease; For those who did not perform destructive treatments the main reason was that they were not aware of sufficient evidence for its use n = 98 (30.2%) and had no experience nor training n = 33 (10.25%). Cold coagulation was the most common destructive treatment n = 100 (31%) that colposcopists could perform, with diathermy n = 70 (22%), laser n = 11 (3.4%) and cryotherapy n = 10 (3.1%) being less prevalent. The majority of colposcopists took two punch biopsies per patient n = 190 (58.5%), with only n = 45 (13.8%) taking three or more biopsies. Silver nitrate was the most favoured haemostatic technique following punch biopsy n = 217 (66.7%), with n = 269 (87.1%) using no local analgesia. Conclusion A study investigating morbidity and Test of Cure of excisional compared with destructive treatments for high grade CIN would be supported by most participating colposcopists. Variation in practice regarding both treatment and diagnosis exists. This has quality assurance implications for a standardised national screening programme.

Link to more details or full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201606002-00174&LSLINK=80&D=ovft

Consultants as victims of bullying and undermining: A survey of Royal College of Obstetricians and Gynaecologists consultant experiences (2016)

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Type of publication:
Journal article

Author(s):
Shabazz T., Parry-Smith W., *Oates S., Henderson S., Mountfield J.

Citation:
BMJ Open, June 2016, vol./is. 6/6(no pagination)

Abstract:
Objective: To explore incidents of bullying and undermining among obstetrics and gynaecology (O&G) consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine. Design: Questionnaire survey. Setting: Royal College of Obstetricians and Gynaecologists (RCOG). Participants: O&G consultant members/fellows of the RCOG working in the UK. Main outcome measures: Measures included a typology of 4 bullying and undermining consequences from major to coping. Results: There was a 28% (664) response rate of whom 44% (229) responded that they had been persistently bullied or undermined. Victims responded that bullying and undermining is carried out by those senior or at least close in the hierarchy. Of the 278 consultants who answered the question on 'frequency of occurrence', 50% stated that bullying and undermining occurs on half, or more, of all encounters with perpetrators and two-thirds reported that it had lasted more than 3 years. The reported impact on professional and personal life spans a wide spectrum from suicidal ideation, depression and sleep disturbance, and a loss of confidence. Over half reported problems that could compromise patient care. When victims were asked if the problem was being addressed, 73% of those that responded stated that it was not. Conclusions: Significant numbers of consultants in O&G in the UK are victims of bullying and undermining behaviour that puts their own health and patient care at risk. New interventions to tackle the problem, rather than its consequences, are required urgently, together with greater commitment to supporting such interventions.