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Mr Doug BarclayGynaecologist
Ascot Central Women’s Clinic
Auckland
16:30 - 17:25 WS #69: Practical Mirena Insertion and Pipelle Endometrial Sampling
17:35 - 18:30 WS #79: Practical Mirena Insertion and Pipelle Endometrial Sampling (Repeated)
Mr Simon EdmondsGynaecologist
Middlemore Hospital
Auckland
Practical Mirena Insertion and Pipelle Endometrial Sampling
Simon EdmondsDouglas Barclay
Orna McGinn
Why are we doing this session?
Give you a taste…..
Improve your skills
Improve the patient journey
Feedback
Plan for this session
20 minutes on background and pathway for AUB
Case Histories
Videos of pipelle and mirena insertion
Discussion and feedback
Training on models
Why in Primary Care?
1 in 16 women age 30 – 49 years consults her G.P with AUB.
each year
Pre-menopausal women having hysterectomies in NZ
80% (3500) for menorrhagia 1990s
approx 65% or less in 2000s
Risk of hysterectomy under the age of 50
NZ 20%
UK 17%
USA 40%
Denmark 10%
What is menorrhagia?
Subjective Excessive blood loss at time of menstruation
flooding
heavy clots
Objective > 80mls volume loss per menses
Low Hb
Low ferritin
Does not matter, unless symptomatic
Cultural
Racial
Religious
Personal
Diagnosis of exclusionDysfunctional uterine bleeding, acute PID
Fibroids outside cavity or submucous…
Polyps…
Endometrial hyperplasia..
Endometrial cancer..
Cervical cancer
Clotting abnormalities etc…
Why is it an issue now?
Commonest cause of iron deficiency anaemia in women of reproductive
age
Significantly affects QoL scores ltd to house
socially embarassing
inability to work
expensive
….even if normal Hb
CMDHB Grading
Between 100 - 150 GP referrals per week (now e-referrals)
15-20% colposcopy
Of the remaining: 22% are for Menorrhagia approx. 800 per year
Virtual letters fertility/PCOS/insufficient info/ Mx plans
Who should Manage it?
At least 70% of case are due to DUB
dysfunctional uterine bleeding
‘just the hormones’
‘hormone imbalance’
NO ‘true pathology’ that requires surgery……..
So why not manage in primary care?
Secondary/Tertiary Care
Interface
Providing the tools to assist primary care in:
diagnosis
referral for further tests
recommended treatment pathways
referral for specific surgical treatment
Tools and resources
Appropriate training -guidelines
-practical training in pipelle/mirena
Appropriate access to tests -ultrasound
Appropriate renumeration/time
What can Primary Care do?
Medical Management tranexamic/mefenamic acid
provera/NET D5-25
POP/COCP/Depo P/Jadelle
Why not the next stage – mirena coil insertion?
Who do you investigate further and how?
Ultrasound scanning……………..
Endometrial pipelle sampling..
ET
Polyps Fibroids
Why is BMI an issue?Women >90kg or BMI>35 ,
ET>12mm - up to 40% have Endometrial Hyperplasia
ET<12mm - less than 1% have Endometrial hyperplasia
Obesity is the biggest risk factor
What can secondary care do?
Attempt to set out a Pathway:
Facilitate pipelle endometrial sampling by GPs (41)
Provide a training package and credentialling document
Have clear guidelines and flow charts for patient selection
Create funding models for education and pipelle sampling
**BMI
**Age
Has it worked?
Slowly…..!!
Why not? Access to funding/remuneration
Mismatch in payment
Lack of a GP ‘champion’
Dissemination of project
90 patients in 18 months on pathway
?10-14 complete
Changes being made
Project now taken over by new clinical lead in gynaecology at CMH last 12 months
GP liason Womens Health by CMH
Access to repayment through POAC (Orna)
Formal training package for mirena insertion?
Funding of mirena by CMH
Or ?? GPwSI in each PHO
Or ?? National RNZCGP or RANZCOG training programme (limited availability for
training through local sexual health clinics). Payment too.
Feedback please
Case Histories (1)
29 year old woman, Para3
heavy periods 5 months, no IMB
Hb 102
clinical examination normal, normal BMI
3 months of cyclical progesterone, tranexamic acid, iron
No improvement, Hb now 92
Mirena insertion – settled by 6 months, Hb 121
Case Histories (2)
37 year old woman, nulliparous
heavy prolonged periods 12 months, no IMB
Hb 128
clinical examination normal,
BTB on COCP despite biphasic /triphasic preparations
BMI 37
TV U/S ET 10mm and pipelle normal sample
Mirena insertion – settled by 6 months
Case Histories(3)
39 year old woman, nullip, BMI 39
irregular periods 5 months,
Hb 112
clinical examination normal
3 months of cyclical progesterone, tranexamic acid, iron
vs
TV U/S ET 19mm…. Pipelle sample: endometrial hyperplasia
OPD Hysteroscopy Directed Bx simple – Mirena coil
Mirena insertion – settled by 6 months
Case Histories(4)
27 year old woman, Para 1
heavy periods 5 years, BMI 61
Hb 79
clinical examination normal
TV U/S ET 17mm Pipelle at least complex hyperplasia
GA Hysteroscopy – frond like lesion at fundus
Histo: Endometrial CA. MRI stage 1b
TAH + BSO pelvic nodes +ve Stage upgraded
Pipelle Sampling:
Top tips:
Make sure not pregnant - ?urine hcG
No cleaning of the cervix required
No sound needed
Single tooth tenaculum
Don’t pull catheter all the way out..
Mirena insertion:
Conclusions
Consider upskilling in mirena insertion / pipelle sampling
Local DHBs may be interested in setting up clinical
pathways
More work needs to be done:
access to funding
?GPwSI
availability of mirenas non funded
governance and continued
education
Recommended