This week, the Royal College of Obstetricians and Gynaecologists (RCOG) launched an updated version of the patient information resource on outpatient hysteroscopy.
In this blog, Emma Crookes (Lay co-Vice Chair of the RCOG Patient Information Committee) asked Dr Geeta Kumar (Vice President for Clinical Quality) about the procedure and what women and people who have been offered one can expect. Geeta is a Consultant Gynaecologist and has been carrying out hysteroscopy procedures for over 20 years.
What is an outpatient hysteroscopy and why might someone be offered one?
An outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves looking inside your uterus (womb) with a thin telescope. Often a biopsy is also taken from the lining of the uterus (endometrium). There are lots of reasons that you may be referred for OPH. For example, you may be offered one to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The purpose of your appointment is to find the cause of your problem and plan or undertake treatment if needed.
What are some of the benefits of having a hysteroscopy as an outpatient?
Hysteroscopy is a common gynaecological procedure carried out in outpatient departments and remains vital for diagnosing and treating a range of different gynaecological health conditions. We know that lots of different factors will come into a decision a woman makes about where she has a hysteroscopy, including the speed of recovery or concerns about time to be admitted to hospital admission due to gynaecology waiting lists.
Many women and people have an acceptable experience of outpatient hysteroscopy with a quick recovery time. For lots of women, having the procedure in an outpatient setting can reduce the time to diagnosis and mean they receive the right care quicker, but for other women it may not be best option.
When I had this procedure, I found it very painful. Why can this procedure be so painful?
We know that most women will experience some pain when they have this procedure, and for some women it can be severe. It is really difficult to predict who will experience the most pain. There are certain features that can potentially predict a more painful procedure for example, if somebody gets very severe period pain or finds smears or speculum examinations painful. This doesn’t always mean that they will not tolerate outpatient hysteroscopy – and it’s important to pre-warn all women and make sure that you discuss the options for pain relief beforehand.
What kind of pain relief is available?
There are a range of different options available. Your healthcare professional should talk you through the risks and benefits of each to help you reach at a decision as to what is best for you.
You will be advised to take some over the counter pain relief medications before your procedure as standard. Your healthcare professional may also offer a local anaesthetic injection into your cervix. This is usually offered when the cervix needs to be stretched to allow the hysteroscope to pass, and local anaesthetic may reduce the pain that this can cause. To give this they will need to use a speculum to see your cervix.
You may sometimes be offered an injection of local anaesthetic to the uterus especially prior to procedures such as endometrial ablation. The local anaesthetic injection itself can be painful but it takes effect very quickly.
Some hospitals may offer pain relief that you breathe, such as Entonox (nitrous oxide) or Penthrox (methoxyflurane), to help with your pain. If you use this, you may be advised to wait a bit longer in the hospital to recover before you can drive. You may wish to use other ways to manage pain, depending on the situation, such as a heat pack, music and other distraction techniques.
It is also really important to know that you do not have to have your hysteroscopy as an outpatient, you can choose to have your hysteroscopy with an anaesthetic (general or regional anaesthetic), or sedation. This will be done in an operating theatre setting, usually as a daycase procedure.
What advice would you give to someone who has been referred for an outpatient hysteroscopy to prepare for their appointment?
My advice would be to consider pros and cons of different settings for this procedure to help decide what is right for you. There are lots of things to consider including type of pain relief and treatment location. Your healthcare professional is there to help you reach this decision by providing all in the information you need to make a fully informed choice. Ask as many questions as you find helpful! You can also ask for your partner, family member or friend to be in the room to support you, if you wish.
As this is a physical examination, is there any other support available for someone who is worried about this?
You’re right, the nature of gynaecological care means that internal examinations are often necessary. For some women, including those who have experienced trauma, physical or sexual abuse, such examinations can be very difficult.
As healthcare professionals, we are there to provide personalised and compassionate care to you. After explaining to you about the physical examination you are being offered, your healthcare professional will seek your consent. They will also explain the alternative options if you choose not to be examined at all.
If you feel uncomfortable, anxious, distressed or in pain at any time before, during, or after an examination, please let your healthcare professionals know, as they are there to support you.
If you find this difficult to talk about, you may communicate your feelings with the health care professional in writing or with the support of someone you wish to accompany you.
What is the RCOG is doing to try to ensure women have the best experience possible of this procedure?
At the RCOG, we produce clinical guidance for healthcare professionals and patient information resources to support the provision of evidence-based, high-quality care. We have developed a suite of guidance on this topic to not only improve clinical quality and reduce variation in practice but also to provide women and people with clear information around what to expect from an outpatient hysteroscopy appointment to support informed decision making.
We know that some women have had poor experiences of hysteroscopy in outpatient settings. We have listened to these experiences and updated this resource to include better information on pain and available pain relief options, alternative options and the importance of informed consent.
An important part of improving women and people’s experience is providing them with the necessary information to make an informed choice about having an outpatient hysteroscopy, and ensuring they feel listened to before, during and after the procedure.
It is also vital that healthcare professionals delivering care follow the RCOG’s guidelines closely and carefully counsel women on the benefits and risks of this procedure before obtaining their informed consent. At the College, we will also continue to urge organisations to implement our clinical guidelines as best practice. This will help to ensure all women and people receive the same standard of care.