8Gynaecology - PDF document

1 8Gynaecology 1Summary secondary preventi
8Gynaecology 1Summary secondary prevention 456Gynaecology In primary care gynaecology accounts for some 1500 consultations per 10000 female population and 2250consultations per 10000 womenyears at risk. A further 500 women consult per 10000 womenrisk with 700 consultations per 10000 women years at risk for candida and trichomoniasis infections ofa)candidiasisb)disorders of menstruationc)menopaused)pelvic pain e)PID.100000 female population for the main gynaecological ICD codes, of which 2000 are for gynaecology anda)disorders of menstruationb)non-inc)genital prolapsed)the menopause. The operative intervention rate is estimated at 3000 per 100000 females over the age of 15. The majora)dilatation and curettage (D&C)b)evacuation of the retained products of conception (ERPC)c)hysterectomyd)laparoscopye)prolapse operations f)operations of the vagina and cer

2 vix. Gynaecology457 section6. 458Gynae
vix. Gynaecology457 section6. 458Gynaecology stress incontinence Gynaecology459 secondary prevention 460Gynaecology a)the initial management of subfertility and follow-up after b)the prevention and management of PID and lower genital tract infectionsc)the management of the menopaused)the medical management of incontinencee)the initial management of menstrual disturbancef)the management of chronic pelvic pain and PMSg)the follow-up of an abnormal smear. Gynaecology461 A comprehensive subfertility service for a population of 100000 will result in around 100 referrals andcost around £300000 per year, including the additional costs for neonatal care. The total cost to the NHScosts has been estimated to be just under £900000 (1992 prices).there be at least one secondary care service per 500000 population and one tertiary centre per 2 millionfemale pop

3 ulation of 500000. 462Gynaecology secon
ulation of 500000. 462Gynaecology secondary prevention100000 women but this estimate requires local adaptation depending on the policy for colposcopy forfollow-up sessions per 100000 women. sessions under Gynaecology463 episodes. The2Introduction and statement of the problema)the secondary to primary care sector. b)inpatient to day case surgery.c)conventional surgery to MAS. 464Gynaecology Box 1:Levels of gynaecological service
prevention
secondary prevention
primary care consultation
primary care procedure
outpatient consultation
outpatient procedure
day care procedure
inpatient assessment
inpatient procedure
palliative care for some 1500 consultations per 100000 female population in primary careadmissions per 100000 female population into hospital in the UKsuggest a rate of nearly 3000 per 100000 female population. The consultation rate in primary c

4 are excludes Regional centres provide sp
are excludes Regional centres provide specialist services for oncology and radiotherapy and advanced treatments forsubfertility, such as IVF. Whether a hospital has a urodynamic service for women suffering fromincontinence or clinics for problems relating to the menopause depends on the interests of the consultants.Psychosexual counselling may also be offered in some departments but is not considered further as noroutine data are available.It is unusual for individual consultants to provide only an obstetric service or a gynaecology service; thenormal pattern is for each doctor to cover both services. The junior medical staff in larger departments mayhave separate duties during weekdays and when on call out of hours. In terms of the physical arrangements,the obstetric facilities (clinic accommodation, antenatal and postnatal wards, delivery suites, obst

5 etric theatreand maternity nursery) in m
etric theatreand maternity nursery) in many hospitals are separate from the gynaecology facilities. The obstetric unit maybe in a separate building adjacent to the main hospital building or even in a hospital in a different location.Over a third of hospital departments of obstetrics and gynaecology in England and Wales are on split sites.33Gynaecological services are provided by specialists who also manage pregnancy and its complications.There is an arbitrary division of pregnancy into that managed by the gynaecological service and that by theobstetric service. This relates to early pregnancy loss during the rst half of pregnancy, before viability of thefetus, which is managed in the gynaecological service. Termination of pregnancy has been considered inanother needs assessment.1 Gynaecology465 In total there were 2000 ordinary admissions to hospital p

6 er 100000 women for non-pregnant conditi
er 100000 women for non-pregnant conditions.Taking both the general practice survey consultation rate of 150 per 100000 female populationThere were additionally 5000 admissions per 100000 women for pregnancy-related gynaecological secondary prevention Family planning services and GU medicine are covered elsewhere in the series.Day case and minimal access gynaecological surgery In the 1990s there have been directives from the Department of Health and consequently purchasers toreduce the use of inpatient beds and expand the use of day surgery. There has also been a drive by providersto avail themselves of the emerging technologies for MAS. Both these initiatives affect the gynaecologyservice.Day caseA day case is dened as an individual admitted to hospital for an elective admission, who is discharged homeon the same day and who underwent an operation. Pr

7 ocedures recommended as suitable for day
ocedures recommended as suitable for day surgery areplanned, clean surgical procedures which require a total operating time not exceeding 30 minutes. Theadvantages of day case surgery are that costs are lower, waiting lists reduced, risks of cross-infection andthrombotic complications are reduced and there is greater convenience for patients.Targets for day case surgeryTargets have been set by regions and by the National Audit Ofce34and require local adaptation to take intoaccount socio-economic circumstances and case-mix. 466Gynaecology Procedureupper quartileoptimisticdilatation and curettage73%86%laparoscopy and sterilization16%65%termination of pregnancy40%70%a)how does the cost of new technologies compare with that of existing technologies?b)what additional bene Gynaecology467 3Sub-categories 468Gynaecology primary care, Gynaecology469 has been

8 used to classify the pelvic pain 470Gyna
used to classify the pelvic pain 470Gynaecology less than 500g. secondary prevention Gynaecology471 4Incidence and prevalenceA health authority with a population of 100000 with 18400 women aged 201the role of silent PID, which accounts for more than half of the tubal occlusion found in most clinical2the failure to show that any current PID treatment regimens have a positive impact on future fertility. 472Gynaecology Sub-categoryIncidencePrevalence (females)1 Subfertility92/100 000 (0.5%)2 PID-Chlamydia19/1000 (persons aged 154 Endometriosis1.3% (age 255 Menopause18% total population6 Urinary incontinencewomen (45+) attending8 Pelvic pain10% females (aged 15+)25% (age 15+)9 Premenstrual syndrome2010 Ectopic pregnancy12/100 maternities spontaneous miscarriage recurrent miscarriage cervix CIN III53/100000 females cervix uterus ovary17/100000 females15/1000

9 00 females20/100000 females Taylor-Robin
00 females20/100000 females Taylor-Robinson estimates, conservatively, that genital and associated infections and their sequelae cost theUK at least £50 million a year for diagnosis and treatment.3Chlamydia infections occur twice as frequently as gonorrhoea in most populations studied.65Serotypes Dand K of C. trachomatisare causes of sexually transmitted disease and are an important cause of morbidity.Such infection cause up to half of all mucopurulent or follicular cervicitis and in developed countries up to60% of PID.66There are only a few prevalence studies in general practice, gynaecology or antenatal clinicsettings. In these 5–12% of women of child bearing age have been found to be infected.67–70The organisms that lead to chronic PID and subfertility are those isolated from women often referred toGUM or gynaecology departments and include gonorrhoe

10 a and chlamydia which are reported in KC
a and chlamydia which are reported in KC60 Gynaecology473 1992 just under 9000 cases of gonorrhoea and 66000 cases of non-speciKC60) for both men and women in a reference population of 100000 to be 1140. 474Gynaecology There were nearly 68500 female deaths from myocardial infarction in England and Wales in 1992. Gynaecology475 80ml.1991 population estimates they calculated that this represents about 14000 incident cases (790051000) and345000 (195200272800) prevalent cases. 476Gynaecology secondary preventionwith registration rates of 53 per 100000 females in the UK in 1986 with 13609 registrations.The incidence of ovarian cancer (ICD 183) is approximately 20 per 100000 with endometrial cancer (ICD100000 women) are 12.26 ovary, 8.7 endometrium and 13 cervix. Mortality data show signi100000 for ovary (including other adnexal tumours), 14.3 for endometriu

11 m and 16 for cervix.predominantly a dise
m and 16 for cervix.predominantly a disease of older women, the incidence rising over the age of 30 to more than 50 per 100000Endometrial carcinoma is rare in women under 40 and the incidence rises to around 50 per 100000 in 70 Gynaecology477 Stage I (%)Stage II (%)Stage III (%)Stage IV (%)Ovary1086017Endometrium751465Cervix3535255 FIGO stageOvary (%)Endometrium (%)Cervix (%)I857578II505757III253031IV510.67.8Overall32.767.755 5Services available the number of trainee medical staff has increased and such a unit may be 478Gynaecology consultations to 328 per 10000 femaleOverall 1500 women consult their GPs a year per 10000 womenincluding early pregnancy loss with 2250 consultations per 10000 womenA further 500 women consult per 10000 womenyears at risk with 700 consultations per 10000ConditionICD codePatients consultingper 10000 women–10000 women–yearsCan

12 didiasis11252169062644967662732858362527
didiasis11252169062644967662732858362527839416212198 combined clinics with oncologist and radiotherapist which may be in another department of Gynaecology479 692000 cases in the female reproductive system groups 167500 (24%) were emergency admissions. There were a total of nearly 2000 cases per 100000 female population aged over 15, with a further 5000 forpregnancy related disorders, totalling nearly 7000 per 100000. 480Gynaecology ConditionNumber per 100femalesDisorders of menstruation455ammatory disorders of cervix177Genital prolapse137Menopause and postmenopause117Uterine leiomyoma111 1300000 days which is 1.5% of the total bed days in the UK and 4% of the acute sector according to HESAppendix III lists the operations by OPCS4R codes with a total of 680000 operations, equivalent to nearly3000 per 100000 females over the age of 15. The major operati

13 ons are displayed in Table 6. Exploratio
ons are displayed in Table 6. Exploration ofCurettage of uterus166146Other evacuation of contents of uterus154222Abdominal excision of uterus59376Endoscopic bilateral occlusion of fallopian tubes5096923031Diagnostic endoscopic examination of uterus21853Prolapse operations (P22 and 23)21248Exploration of vagina20538Destruction of lesions of cervix uteri19622 Appendix III details the operation by OPCS4R shortlist and splits ordinary and day cases and bed days. Theproportion of ordinary to day cases varies by type of operation as does the use of bed days. Details of thewaiting times in 1993/94 in the UK by main ICD categories and certain operation types are also given. Thereis signicant regional variation. Appendix III also details the HRG data for 1993/94 in the UK. Overall 37%of the surgical admissions were treated as day cases. The accuracy of the data

14 on ectopic pregnancy andtermination of
on ectopic pregnancy andtermination of pregnancy are questionable as there appear to be a large number of admissions withoutoperation.Overall gynaecological service assessmentThere are no routine data which provide overall cost/resource information for a gynaecology service. Anexample of how such data can be generated is provided by the Scottish Forum for Public Health Medicine. Gynaecology481 ProcedureElective (el)/Outpatient clinics127Inpatient day case129Inpatient case104Hysterectomyel1241Hysterectomyem1628Vaginal repairel1568Vaginal repairem2279Hysteroscopyall231D&Cel404D&Cem597D&Cday case231Open sterilizationel838Laparoscopy/lap. sterilizationel447Laparoscopy/lap. sterilizationem640Laparoscopy/lap. sterilizationday case231Termination of pregnancyel/em431Termination of pregnancyday case231Other operationsel666Other operationsem808Other operationsda

15 y case231 The Scottish Forum for Public
y case231 The Scottish Forum for Public Health Medicine estimated that £15000000 per annum was spent for afemale population of nearly 500000 73% on hospital expenditure. sub-categories GroupUnable toTOP (%)Steril-Prevention13.00Primary care1.49.001.11.21.0013.7OP clinics15.33.00OP procedures1.3Day case surgery0.80.10.10.020.30.22.50.60.31.76.62IP surgery5.22.92.72.001.71.412.005.53.002.007.545.9IP no surgery0.40.72.70.010.050.040.20.20.024.79.02IP terminal care0.20.030.23 OP = outpatient, IP = inpatient Gynaecology483 and vulva (ICD 615, 616). The combined inpatient rates equate to 160 per 100000 women aged over 15. It iss gland with an operation rate of 23 per 100000 femaleinfection per 100000 population aged 15trichomoniasis has declined to a rate of nearly 50 per 100000 female population aged 15The number of new cases of candidiasis recorded in GUM

16 clinics has remained at about 60000 per
clinics has remained at about 60000 per yearthere were 18 hospital admissions for endometriosis per 100000 women aged 15 484Gynaecology 32 operations per 100000 female population aged over 15. The overall admission rate equates to a rate of nearly 140 per 100000 females aged over 15 years.Prolapse procedures utilize 242000 bed days with a mean length of stay of eight days, median six.Repair of prolapse operations occur at a rate of 100 per 100000 women aged over 15. A total of 822000prescriptions were issued in the UK in 1993 to 345000 women for menorrhagia at an annual cost of £7.12 dilation of cervix uteri abdominal excision of uterusleiomyomata of the uterus is 111 per 100000 female population aged over 15. Disorders of menstruationaccounted for a further 455 admissions per 100000 female population aged over 15. Gynaecology485 static in the UK, with

17 a rate of 70 per 10000 women in the UK c
a rate of 70 per 10000 women in the UK compared with 11 in the US in 19881993/94 22000 hysteroscopies were carried out in the UK, an increase of 22% on 1992/93.10000 women in 1989/90. 486Gynaecology operations. Data from the HES indicate that there were 1170192 inpatient cases equating to 5000 per100000 female population aged over 15. secondary prevention smears and implementation of treatment (fail-safe protocols) is the area of theData from the HES indicate an admission rate of 84 per 100000 female population aged over 15 for10000 patients.There were 38712 inpatient admissions, equating to a rate of nearly 500 per 100000 Gynaecology487 Operation%s abscess/cyst13D&C44ERPC35Diagnostic endoscopy55Therapeutic endoscopy15 preference for traditional approaches6Effectiveness of services 488Gynaecology SubfertilityActive and sensitive provision of informati

18 on and support are important components
on and support are important components of a high qualitysubfertility service. Stress is reduced in those couples who feel involved in and in control of their treatment(A-III).125The role of counselling has not been shown to be effective.Assisted conception techniques include articial insemination, IVF-ET (in vitrofertilization and embryotransfer) and GIFT (gamete intra-fallopian transfer). In 1990 the average pregnancy rate with IVF-ET was17% per treatment cycle.2This translates into an average maternity rate of 12% (per treatment cycle) and14% per couple treated because some couples have more than one cycle. The average number of treatmentcycles per patient in 1990 in the UK was 1.162and three cycles is considered by experts to be a reasonablelimit. There is no evidence of increased effectiveness overall of IVF-ET over GIFT. The effectiveness of IVF

19 is reduced if the sperm used is of poor
is reduced if the sperm used is of poor quality; effectiveness is also inuenced bymaternal age (AIII).2In vitrofertilization clinics providing a service for women aged over 35 have lower thanaverage success rates.2Fetal abnormality occurs but not at statistically different levels to unassistedconceptions.126Maternal mortality and morbidity data are not available but recommendations that multiplepregnancies should be avoided have been made (AIII).2The problem that is managed least successfully in terms of conceptions has been that of poor sperm qualityor function; there is currently no completely effective treatment for male infertility. The administration ofsystemic corticosteroids to the 10% of men thought to have an immunological basis to their sterility is ofdoubtful efcacy and treatment may produce unpleasant and often unacceptable side-effects.42

20 ,127The mainsuccess in managing male inf
,127The mainsuccess in managing male infertility is by articial insemination by donor (AID) and the provision of donorinsemination should be an integral part of a district infertility service. There will also be a small demand forthis service for the partners of males who are HIV positive and wish to conceive. There may be an increasedneed for AID, as the extent of male infertility becomes clinically recognized.Medical treatments for ovulatory dysfunction caused by hyperprolactinaemia or hypothalamicamenorrhoea appear to be very effective at re-establishing fertility to normal levels (AII-2).128There is a signicant level of spontaneous pregnancy among untreated women with endometriosis andmedical and surgical treatments have been shown to be ineffective. For couples who have failed to conceive,where mild or moderate endometriosis is implicated, assist

21 ed conception techniques appear to be su
ed conception techniques appear to be successful(AII-2).Assisted conception techniques appear the most effective treatment for unexplained subfertility (AII-1).Medical treatments may have some effect upon maternity rates and these require further investigation. Pelvic inßammatory diseaseHealth education as it is currently provided in the school system is thought to have little inuence uponsexual and contraceptive behaviour of young people and hence on PID.129The use of barrier methods of contraception by those not in mutually monogamous relationships is animportant part of any strategy to reduce PID and secondary infertility caused by sexually transmitteddiseases (AIII).Apart from primary prevention early diagnosis and treatment of sexually transmitted diseases plays animportant part in reducing their incidence by shortening the time during which peopl

22 e can pass on infectionto others (AIII).
e can pass on infectionto others (AIII). Strategies for detection and screening have been haphazard, so that the identication ofinfected individuals, with or without symptoms has been incomplete.3In Sweden a programme ofwidespread screening for chlamydial infection has virtually eradicated the disease.4There is evidencehowever that a small increase in 15–19 year olds may herald a resurgence and the differences between theSwedish population and that in the UK may mean such a reduction would not be seen in this country. High Gynaecology489 risk screening of women undergoing termination of pregnancy has been suggested as a more cost-effectiveway forward (BII-2).130In primary care it has been modelled that a routine test for chlamydial infection inasymptomatic 18–24 year old women during gynaecological examination was found to be cost-effective butthis was

23 not the case for older women (BIV).5Chl
not the case for older women (BIV).5Chlamydia trachomatiscan be diagnosed from swabs detecting endocervical chlamydial antigens andserum chlamydial antibodies but the woman may not present as she is often asymptomatic. The tests areexpensive. A ligase chain reaction assay of urine to diagnose Chlamydia trachomatishas been shown to behighly effective for its detection in urine from women with or without symptoms of chlamydial genitourinarytract infection.131Standard regimens of tetracyclines, doxycycline or erythromycin appear to be effectiveagainst chlamydia in most circumstances (AI).132A meta-analysis of trials of antibiotics to treat PID indicatedthere was a lack of uniformity among studies regarding diagnosis, care and follow-up. Pooled cure ratesranged from 75–94%. Doxycycline and metronidazole was the least effective regimen (75% cure rate).Cipro

24 oxacin was the cheapest.133They conclud
oxacin was the cheapest.133They concluded that clinical treatment of acute PID is still likely to bewholly inappropriate in many women and suboptimal in a high proportion of the remainder.Lower genital tract infectionsHealth promotion initiates should be in line with local strategies for the Health of the Nation targets.134Contact tracing should become a matter of routine for all diagnosed cases of sexually transmitted disease.Appropriate antimicrobial therapy is effective for chlamydial infection with cure rates of 80–90% (AI).Bacterial vaginosis can be treated with oral metronidazole and clindamycin intravaginal creams, with 75%being disease free one month after treatment (AI)6but whether a single dose or seven-day course is morecost-effective is unclear.Bartholin’s abscesses can either be surgically marsupialized or incised. Andersen et al.(AI) comp

25 aredmarsupialization with incision and c
aredmarsupialization with incision and curettage and primary suture of the abscess under antibiotic cover in aprospective trial of 32 patients.135The time for healing was signicantly less in the suturing group than themarsupialization group, with the same length of stay.EndometriosisThe aetiology and natural history of endometriosis is not known and thus most regimens have not beenshown to be effective in the long term, hence the whole spectrum of strategies employed. Currently clearrecommendations for treatment of endometriosis in symptomatic women can be made.45Medical treatmentworks only temporarily with the disease recurring once stimulation by ovarian steroids returns.136Endometriosis is more common in subfertile women and women with pelvic pain and logically these shouldbe the main indications for treatment.45None of the trials show that medical

26 treatment improves fertility.45Hormonal
treatment improves fertility.45Hormonal treatment of symptomatic endometriosis is less of an issue if pain interferes with quality of life.As treatment is expensive and with side-effects the therapy should be contingent on the goals of treatment foreach patient. Several modalities can be employed in managing the patient with endometriosis but theultimate selection is determined by evaluating a number of criteria including age, extent of disease, severityof symptom and pain. Treatment with progestogens alone has apparently been successful but they are prescribed less frequentlythan the androgenic steroid danazol.137Danazol reduces breakthrough bleeding but there is no evidence thatpregnancy rates are any higher with this drug than progestogens.138A newer approach is ovarian suppressionwith luteinizing hormone releasing hormone (LHRH) analogues. However b

27 oth danazol and LHRH arecostly and have
oth danazol and LHRH arecostly and have limitations for long-term use. Large multicentre trials of GnRH and danazol show equal 490Gynaecology effectiveness in relieving symptoms and resolving visible endometriotic lesions (AI).139,140Both preparationshave side-effects that need to be considered when managing patients.All medical approaches seem to offer relief of symptoms but the optimum duration of treatment is notclear and the relative merits in terms of pregnancy rates, disease eradication, side-effects and long-termbenets or disadvantages have yet to be compared with each other, with surgical methods and, in mild cases,with placebo. For women wanting to become pregnant surgical intervention is indicated in those with moderate orsevere disease associated with ovarian xation, peritubal adhesions, or ovarian endometriomas (BIII). Ifsurgery is indicat

28 ed electrodiathermy is the conventional
ed electrodiathermy is the conventional method with laser a more expensive alternative butone which allows treatment at the same procedure as diagnosis (BIII).141Comparison of conservative surgerywith medical treatment or expectant management has shown no difference in the outcome in women withmild or even moderate endometriosis.137,142,143Likewise a combined surgical and medical approach seems tooffer no advantage in mild disease, although it is the method most favoured in advanced cases.137,142,143The Effective Health Care Bulletinon the management of subfertility states that there is a signicant levelof spontaneous pregnancy among untreated women with endometriosis. Medical treatments have beenshown to be ineffective. Surgical treatments also appear ineffective. For couples who have failed to conceivenaturally assisted conception techniques appear s

29 uccessful (AII-2).42The debate about man
uccessful (AII-2).42The debate about management continues and results of large trials on which to base rational managementare awaited. Although there is a move to minimally invasive techniques for the treatment of endometriosistheir effectiveness remains to be conrmed in controlled clinical trials. A study in Leeds suggested that if a patient has a recurrence of endometriosis it may be possible for the GPto initiate retreatment with the same or alternative medication prior to a revaluation by the gynaecologicalteam (CIII).144Surveillance and continuing prescription in primary care is required after hospitalmanagement.Menopause and hormone replacement therapyThis assessment is predominantly concerned with the effectiveness of the gynaecological services. Thedebate over the effectiveness of HRT on chronic diseases such as osteoporosis, breast cancer andc

30 ardiovascular disease continues and only
ardiovascular disease continues and only an outline is provided here but it is important to ensure that wheremenopause services are provided, information and management strategies incorporate consideration of thelonger term benets of HRT.SymptomsPlacebo-controlled trials have shown consistently that HRT relieves ushes, sweats and the symptoms oflower genital tract atrophy and most have reported benecial psychological effects (AI).8Cardiovascular diseaseMeade and Berra reviewing 12 retrospective case-control studies suggested that HRT reduced coronary riskby about 25% but little or no effect was seen for stroke (AII-2).9Reviewing the ten prospective cohort studiesreductions of 20% for cardiovascular disease and 15% for stroke were observed (AII-2). There are nocomparable data of treatment with patches or implants. It is not known whether opposed oestr

31 ogen therapydiminishes these benecial e
ogen therapydiminishes these benecial effects as progesterone reduces the HDL cholesterol-raising effect of oestrogen.In the prospective studies notably the nurses study in the US it is not clear how much of the observed Gynaecology491 Decision analysis was used to assess the value of HRT in a hypothetical cohort of 10000 women assumed 492Gynaecology StrokeBreastEstimated annual rates per 100000by age group54 years30176221864 years1716010186674 years6002431351623175+ years24191938259341480Relative risk0.60.81.24.00.5Change in annual rates per 100000 by age group3+12+812+20+3249+27+64388+52+136Relative risk0.80.91.31.00.5Change in annual rates per 100000 by age group2+1806+30024+410484194+780 aIschaemic heart disease, cerebrovascular disease, breast cancer, endometrial cancer mortality rates from OPCS;hip fracture estimated incidence rates from HIPE dat

32 acompliance with HRT and much of the dat
acompliance with HRT and much of the data was derived from the nurses study in the US and may not berepresentative of the UK situation. Khaw illustrated the estimated changes in annual rates of certainmenopause related events of ten years HRT (Table 10).47Mode of deliveryThe oestradiol patch is an alternative to oral oestrogens for women with menopause symptoms. It should becombined with an oral progestogen for women who have not had a hysterectomy. The theoretical advantageof the transdermal route is of unproven clinical benet and the contraindications are the same as for oralHRT. Patches are not yet indicated for preventing osteoporosis and are more expensive than other oestrogenpreparations. It is still not yet known whether transdermal oestradiol will protect against ischaemic heartdisease in the way that ovarian or oral oestrogen does. Subcutaneou

33 s oestrogen is more effective than oralo
s oestrogen is more effective than oraloestrogen in preventing osteoporosis, probably owing to the more physiological (premenopausal) serumoestradiol concentrations achieved. Subcutaneous oestrogen also avoids problems of compliance that occurwith oral treatment.152Progestogen-releasing intrauterine systems can also be used to deliver progestogendirect to the endometrium in women who still have a uterus. Gynaecology493 was found to be cost-effective with rates ranging between $9130 and $12620 per additional life saved.vertebrae. Under these assumptions combined therapy was more costly, with ratios ranging from $86100 to$88500. CostsORT (£)O+P (£)Drug110453Monitoring117117Breast cancer1313Ischaemic heart disease(18)(9)Cerebrovascular disease(65)(33)Fractured neck of femur(20)(20)Total cost137521 Figures in paranthesis are savings. All costs are discounte

34 d at 5% per annum.12ORT = oestrogen repl
d at 5% per annum.12ORT = oestrogen replacement therapy.O+P = oestrogen plus progesterone.Coulter has estimated that 20% of the female population in the UK will have had a hysterectomy by the ageof 50 and thus a strategy aimed at this group alone would have major public health implications.118AsWeinstein and Tosteson indicate all conclusions from such analyses must be regarded as highly speculativebecause of the vast uncertainty that surrounds the possible effects of oestrogen and progesterone on heartdisease.153In terms of cost-effectiveness they conclude that HRT compares favourably with other acceptedhealth care interventions. Daly et al.similarly concluded that long-term prophylactic treatment ofhysterectomized women and treatment of symptomatic women with a uterus compare favourably with otheraccepted health care interventions.154They estimated the

35 cost per QALY to range from £700 for te
cost per QALY to range from £700 for ten years oftreatment with oestrogen alone HRT for women with mild menopausal symptoms to £6200 for combinedtherapy for women with mild symptoms.Grady et al.estimated life expectancies and risks of certain sentinel events in groups: women without risk,women with cardiovascular disease and women at risk of breast cancer, fractured neck of femur, orcardiovascular disease.150Assumptions had to be made for the long-term effect of combined therapy. In the 494Gynaecology 1simple and non-invasive (e.g. pad tests and frequency/volume charts), suitable for primary care2basic urodynamics suitable for district general hospitals3complex urodynamics suitable for a tertiary referral centre. Gynaecology495 ileocystoplasty is amongst the more effective 496Gynaecology progestogens, such as norethisterone. Gynaecology497 and a mort

36 ality rate of six per 10000. 498Gynaecol
ality rate of six per 10000. 498Gynaecology Alternatives to total abdominal hysterectomy An abdominal hysterectomy takes 45–60 minutes to perform and women may need to remain in hospital forup to seven days with 9–11 weeks convalescence.41,190Endometrial ablation can be performed by transcervical resection of the endometrium (TCRE),coagulation with a rollerball electrode, laser ablation or radiofrequency-induced thermal ablation. With laserablation most patients are discharged after an overnight stay in hospital and return to full activities within tendays.191Rollerball coagulation takes about 25 minutes and most patients return to full activity within oneweek, with 30–40% of women becoming amenorrhoeic and 55–60% having reduced menstrual ows whichis similar to the results of laser ablation and radiofrequency-induced thermal ablation.191–193Dwyer et al

37 .demonstrated reduced morbidity with TCR
.demonstrated reduced morbidity with TCRE compared with TAH (AI) with a follow-upperiod of four months at which point there was a 10% failure rate with TCRE. This trial had a 46%morbidity rate with TAH and 25% psychiatric morbidity rate which is similar to previous studies. There wasless satisfaction with TCRE than TAH, although satisfaction levels were high (85% TCRE, 94% TAH).Sculpher et al.analysing the same trial data concluded that up to four months post-operation TCRE had acost advantage over abdominal hysterectomy in terms of health service resource costs.15However given thefact that a group of women required retreatment due to resection failure and that follow-up was short thelong-term cost and benets of endometrial resection need to be evaluated before widespread diffusion isjustied. The cost of TCRE was estimated at £560 (range £420–£1691) v

38 ersus TAH at £1060 (range£826–£2278). Th
ersus TAH at £1060 (range£826–£2278). These costings took no account of time off work which was four to ve times longer afterhysterectomy than TCRE. In another trial Gannonet al. concluded that for women with menorrhagia whohave no pelvic pathology TCRE is a useful alternative to abdominal hysterectomy, with many short-termbenets (AI).189These studies did not compare TCRE with vaginal hysterectomy.Pinion et al.compared TAH, TCRE and endometrial laser ablation in a trial of 204 women with DUB.194Hysteroscopic endometrial ablation was superior in terms of operative complications and post-operativerecovery. Satisfaction after hysterectomy was signicantly higher but between 70% and 90% of the womenwere satised with the outcome of hysteroscopic surgery. The hysteroscopic procedures were signicantlyshorter and lengths of stay shorter (7.5 days TAH, 2.5 d

39 ays hysteroscopic) (AI). In a non-random
ays hysteroscopic) (AI). In a non-randomized studyMagos et al.followed-up TCRE patients for up to 2.5 years.195Results were best in women aged over 35 yearsand 4% underwent hysterectomy at a later date and menstrual symptoms were improved in over 90% ofpatients (AII-2).Transcervical resection of the endometrium requires extensive training.196Laparoscopically assisted vaginal hysterectomyAn argument for performing oophorectomy at the time of hysterectomy has been put forward to prevent theoccurrence of subsequent ovarian pathology, although this is debated vigorously and the issue of consent iscrucial.46To reduce the morbidity and use of resources associated with TAH a laparoscopically assistedvaginal hysterectomy may allow a vaginal hysterectomy to be performed with removal of the ovarieslaparoscopically. Hunter et al.reviewing the procedure undertaken

40 on a case series concluded that LAVHcan
on a case series concluded that LAVHcan be successful in most women selected for the procedure and there appears to be rapid return to normalactivities and work (CII-2).197Boike et al.reviewing the literature concluded that despite the reduced lengthof stay LAVH was more expensive but was a useful technique for converting some TAHs into vaginalprocedures if adnexal procedures were indicated.198Raju and Auld in a trial of 80 women with uterine size ofless than 14 weeks demonstrated reduced lengths of stay and subsequent costs with similar morbidity rates inLAVH patients.16The debate as to whether to perform a vaginal hysterectomy or LAVH is ongoing anddepends on the evidence of effectiveness of prophylactic oophorectomy (BI). Summitt et al.in the UScompared LAVH with vaginal hysterectomy in an outpatient setting and concluded that other than LAVH Gynaeco

41 logy499 extremely rare (1 per 30000 preg
logy499 extremely rare (1 per 30000 pregnancies). Human chorionic gonadotrophin (HCG) estimation remains the 500Gynaecology outcome (rather than a decrease of miscarriage alone) of high-risk Gynaecology501 incidence had fallen mainly in the well-screened age group of 40Ð69 years (AII-2 in Scotland).Mild and moderate dyskaryosis will be identiÞed in 1Ð2% of women screened and of these around 30% willmildly dyskaryotic may represent 4Ð5% of all smears. Because of the paucity of information available towithin six months. Alternatively two to three consecutive negative smears should be obtained within 12Ð18 502Gynaecology colposcopy indicates that training to a clinical assistant level is required and proper equipment and nursingback up is essential. Evidence must be available to demonstrate a particular GP will perform sufÞcientprocedures to maintain prof

42 essional expertise.The International Age
essional expertise.The International Agency for Research into Cancer study of screening histories comparing women whodeveloped invasive cervical cancer with those that did not demonstrated that the relative protection againstcervical cancer in women with two or more previously negative smears participating in centrally organizedscreening programmes is 15-fold in Þrst year, 12-fold in second and eight-fold in the third year, indicatingthat screening is effective if coverage is high (AII-2).227Centrally organized programmes were more effectivethan uncoordinated screening. Case-control studies have illustrated similar relative protection for those whohave had a smear less than three years previously.228,229Cervical intraepithelial neoplasia is arbitrarily classiÞed as CIN I, II or III but many pathologists considerit a continuum from mild at one end to und

43 ifferentiated at the other. There is gen
ifferentiated at the other. There is general agreement that highgrade (CIN III) lesions should be treated (AII-2) but the natural history and consequently management oflesser degrees of abnormality remains somewhat unclear. The NHS cervical screening programme does notrecommend immediate colposcopy for CIN I. The results of the Aberdeen Birthright study conclude thatcytological surveillance, although safe, is not an efÞcient strategy for managing women with mildly abnormalsmears, although a detailed cost-effectiveness analysis has not been presented.230They suggest women withany degree of dyskaryosis in a smear should be referred for colposcopy as only one in four women with milddyskariosis reverted to normal over the two-year study period. The other important Þnding of the Aberdeenstudy was that one-third of women with CIN III had an index smear showin

44 g mild dyskariosis and that one ineight
g mild dyskariosis and that one ineight women defaulted from follow-up. Routine colposcopy would lead to 30% more referrals but wouldreduce cytological surveillance. The remaining potential disadvantage of immediate referral is the risk ofovertreatment.231 Although large-loop excision of the transformation zone is safe and effective (AI)232unnecessary treatment should be avoided. Without data from other prospective studies we must rely oncross-sectional and retrospective studies. All large studies have suggested that cytological surveillance is safeboth individually and at a poulation level.233,234The smears of up to half the women will return to normalwithout treatment. The semi-quantitative polymerase chain reaction may allow a distinction between highand low grade disease in women with mild cytological abnormalities but needs large population-basedst

45 udies.235There is currently no routine c
udies.235There is currently no routine clinical role for cervicography in either primary cervical screening or in thefurther assessment of patients with abnormal cytology. Although there may be a role for cervicography in thesurveillance of patients with mild dyskaryosis or borderline changes to reduce the frequency of referral forformal colposcopy this requires further evaluation.28,236There is similarly no international agreement on the management of CIN II or III (moderate and severedysplasia and carcinoma in situ) which constitute 1.5Ð2% of all smears. Colposcopy is indicated with biopsyof abnormal areas and treatment if CIN II or more is diagnosed. CIN II or III can be treated either by local destructive therapy or conization of the cervix. Local treatmentmay be cryotherapy, heat coagulation, laser coagulation or loop excision. Conization may be by

46 cold knifeconization, electric cautery
cold knifeconization, electric cautery or laser. It is generally agreed that the method of treatment is not considered to beof particular importance with regard to outcome, provided the pathologist receives some material forexamination.28The mode of treatment may have relevance when deciding service provision options.Large-loop excision of the transformation zone (LLETZ) has enabled the colposcopist to make a diagnosisand treatment at just one outpatient visit without the need for pre-treatment cervical biopsy (AI).232,237Therehas been some concern over the pathological interpretation of the margins of such a procedure.238Acontrolled trial of LLETZ versus carbon dioxide laser vapourization showed reduced operative time,post-operative haemorrhage and discomfort in the LLETZ group. There was no signiÞcant difference inCIN recurrence rates. There are redu

47 ced capital outlays for LLETZ treatment.
ced capital outlays for LLETZ treatment.239A randomized controlled Gynaecology503 being affected given a positive result in the general population would be about 1:12. A full RCT of ovarian 504Gynaecology was not Gynaecology505 7Models of care 506Gynaecology surgery InformationInforming women about speciÞc gynaecological conditions and their management, especially operativeprocedures and what to anticipate post-operatively, in a letter or leaßet, is necessary. These informationleaßets should be co-ordinated across the levels of care, providing the same messages.The RCOG has produced standards for communication for common surgical procedures and a series ofpatient leaßets on common gynaecological disorders. The Audit Committee consider communications vitallyimportant and worthy of audit.259 Gynaecology507 Sensitive provision of information is considere

48 d an important component of the subferti
d an important component of the subfertility service andstress is reduced in those couples who feel involved in and in control of their treatment.125Information regarding the prevention of lower genital tract infections and PID should be produced inconjunction with health education departments and GUM clinics and be in line with local Health of theNation strategies.Roberts113illustrated the need for more information provision for women about the menopause before itsonset and about HRT.Versi et al.157 advocate the use of explanatory materials for women with urinary incontinence which couldbe developed in conjunction with the community incontinence advisors.Many units have leaßets which discuss menstrual disturbances and their management. They provideinformation on the options for treatment and the effects of treatment. There are widely available books on

49 hysterectomy for the lay public which ad
hysterectomy for the lay public which address questions commonly asked by patients.Gilling-Smithet al.showed that the use of advisory leaßets to patients on discharge from hospitalsigniÞcantly enhanced the service provided to women with miscarriage.121Leaßets explaining what an abnormal smear means and how it is managed should be provided incolposcopy clinics and be written in conjunction with the local cervical cancer screening group. Informationregarding cancer and palliative care should also be available and developed by the cancer centres inconjunction with services supporting women when they leave secondary care e.g. hospices and Macmillannurses.Monitoring patient satisfactionIn general within the NHS there are moves to monitor patient satisfaction with the service. The surveys needto have a representative sampling frame and a good response rate to

50 be of beneÞt to those delivering care.
be of beneÞt to those delivering care. Theareas for questioning could include outpatient facilities, day case surgery, inpatient stay and follow-up.Satisfaction surveys should be an integral part of any service or intervention evaluation.Shift to primary careAlthough there are initiatives to shift services to primary care the evidence for their cost-effectiveness isusually not available and evaluation of these shifts needs to be an integral part of contract speciÞcation. Shiftscan either be to management in a community setting by community gynaecologists, often linked withreproductive health services, management by health care professionals in general practice or management bysecondary care gynaecologists in primary care. The latter has become an increasing trend in districts withfundholding general practices but the evidence for their effectiveness is

51 lacking and some consider them to bean
lacking and some consider them to bean inappropriate use of resource, few practices having enough patients to sustain outpatient clinics.Any shift from secondary care should have the aim of providing a more co-ordinated service with reducedduplication of the process of care which currently occurs when care is split between sectors. The shift shouldbe facilitated by the development of guidelines to increase the appropriateness of care. This assessment hasestimated that for every eight women consulting in primary care only one ordinary admission is generated.The main conditions seen in primary care are detailed in Table 4 and consist of those relating to themanagement of genital infection, menopause, menstrual disturbances and pelvic pain. Unfortunately routinedata in secondary care outpatient clinics are not recorded and it is not clear, other than thro

52 ugh local audits,which conditions are mo
ugh local audits,which conditions are more likely to be referred to secondary care. The case-mix will vary from unit to unitdepending on the skills in primary and secondary care settings but is broadly similar to that seen in primarycare. The HES data conÞrm that menstrual disorders and the menopause are prevalent conditions along with 508Gynaecology must not be overlooked when weighing up the bene element. Gynaecology509 The comprehensive subfertility service for a population of 100000 will result in around 100 referrals andcost around £300000 per year, including the additional costs for neonatal care. The total costs to the NHS,have been estimated to be just under £900000 (1992 prices). 510Gynaecology It is estimated there should be at least one secondary care clinic per 500000 population and one tertiary Gynaecology511 for a female population of ne

53 arly 500000. There is no conclusive evid
arly 500000. There is no conclusive evidence however that physiotherapy is 512Gynaecology Menstrual disordersGuidelines for assessing menstrual disorders in primary and secondary care should be developed locally andinclude a structured history and estimation of haemoglobin or serum ferritin concentrations. Furtherendocrine investigations should be undertaken according to guidelines and completed as efÞciently as isfeasible. The development of guidelines for the medical management of menstrual disturbance in primarycare would appear to be a priority. General practitioners should offer at least one course of effective drugtherapy prior to referral for surgical treatment.115The cost implication in shifting prescribing habits from theuse of norethisterone to tranexamic acid is estimated at 20% of the drug costs but as norethisterone isineffective in the sho

54 rt term, money spent on it is wasted; in
rt term, money spent on it is wasted; in addition many women treated in this way wouldbe referred for surgery. It is also estimated that if tranexamic acid were to replace all other drugs used therewould be a net saving of at least 10% on the total drug bill for menorrhagia.115Drug use in primary careshould be monitored to identify prescribing of relatively ineffective drugs. Criteria for using D&C should be developed and a shift of service to hysteroscopy or other endometrialsampling techniques agreed. The increased use of day case services and see and treat clinics should bedeveloped to enable the Audit Commission targets to be met.34A shift from TAH to TCRE should be agreed. Patients undergoing such procedures as LAVH should beenrolled into trials as the evidence for their use is not established.The Effective Health Care report115recommends that all

55 options should be discussed with the wom
options should be discussed with the woman,allowing her to make an informed choice.Pelvic painGuidelines should be in place to exclude speciÞc gynaecological conditions and non-gynaecological causes ofpelvic pain.270Assessment should include laparoscopy. The trial evidence does not allow conclusions to bedrawn on speciÞc therapies but the need for adequate explanation and possibly counselling should beconsidered, particularly if hysterectomy is to be considered.Premenstrual syndromeCurrently it is assumed that the majority of women with PMS are seen and treated in primary care. Given thecurrent state of knowledge regarding the deÞnition and treatment it seems to be appropriate for the majorityof women. Referral to gynaecology clinics should enable the use of standardized diagnostic scales in thesecondary care settings. Women should be treated following

56 guidelines and entered into trials where
guidelines and entered into trials whereappropriate.Ectopic pregnancy and early pregnancy lossBoth in the US and UK failure of the pregnant woman with an ectopic pregnancy to seek medical attentioncontributes to the death rate. Protocols should be developed both in primary care, A and E andgynaecological departments for the diagnosis of ectopic pregnancy. The ability of GPs to perform pregnancy tests to exclude the possibility of an ectopic pregnancy should beconsidered. All junior medical staff should be made aware of the possibility of an ectopic pregnancy in awoman of reproductive age who presents with pelvic pain or bleeding. Direct access to a diagnosticultrasound scan is a priority which gynaecological departments should consider along with protocols forreferral of women with miscarriage or possible ectopic pregnancy. Referral to an early pregnanc

57 y assessment unit with diagnostic tests
y assessment unit with diagnostic tests and skilled personnel appears to beefÞcient, although the cost-effectiveness of such a service has not been established.214 (D Hamilton-Fairley,personal communication, 1996.) Gynaecology513 secondary prevention 514Gynaecology
Personal invitation to women and health educationAn invitation letter is considered fundamentalto good coverage which gives the women a choice of location for the smear test. 86% of districts give thischoice but only half state where these are.272Only 55% of districts include health leaßets routinely andvery few ethnic minorities whose cultural and religious beliefs may not make the offer of screeningacceptable are targeted. A randomized controlled trial has failed to show any beneÞt from counsellingwomen with an abnormal smear result (CDA Wolfe, personal communication, 1996).The importance

58 of reducing risk factors associated wit
of reducing risk factors associated with cervical cancer needs to be stressed to women. Withadvances in the knowledge of the disease and its aetiology, different information may be given by health careprofessionals in the future but at present discussion of barrier methods of contraception and the possibleassociation of cervical cancer with heavy smoking is advisable. Education of doctors and patients isinadequate and there is a need for a sustained programme of public and professional learning aimed atensuring that the potential beneÞts and requirements of an effective screening programme are appropriatelyunderstood. Education of the women at risk towards an understanding of the objectives of the programme isessential. This is clear from the high incidence of invasive cervical disease occurring in women who havenever been screened.272Efforts must be d

59 irected to ensure that all women, includ
irected to ensure that all women, including those of lowersocioeconomic status, are offered screening programmes. Majeedet al.illustrated how routine data fromFHSAs practice indicators of deprivation could explain over half the variation in cervical smear uptake ratesin terms of census and FHSA data.277These variables may have a role in explaining variations in performanceof practices and in producing adjusted measures of practice performance. Practices with a female partner hadindependent and signiÞcant effects on uptake rates.
Quality of the cervical smear testThere are two components to the false-negative rate of cervicalsmears. 10Ð15% of smears are reported as negative because either cells were not exfoliated or were notpicked up by the person taking the smear.56This may be partly dependent on the type of spatula used totake the smear, certain desig

60 ns being more appropriate in women with
ns being more appropriate in women with varying shapes of cervix. In a studycomparing cytological results with colposcopic biopsy Þndings, Giles reported a 58% false- negative rateon cytology for small lesions (less than two quadrants of the cervix).278This observation is of importanceas 6% of the general population have these lesions on smear.The National Audit OfÞce found that although laboratories were committed to the principles of externalquality assessment, two of the three regions visited did not have it in place. They recommend that purchasersshould specify laboratory fail-safe mechanisms in their service contracts and require regular reports on theirperformance.279 Organization of training programmes, proÞciency-testing and systems of quality control areneeded. A uniform nomenclature for both cytology and histopathology is recommended.
Follow-u

61 p of abnormal smears and implementation
p of abnormal smears and implementation of treatment (fail-safe protocols)In theUK a disturbingly high proportion of women found to have abnormal smears have not been adequatelyinvestigated or treated.280Ellman and Chamberlain found that 13% of patients with invasive cancer werealso not followed up. Elkindet al.273showed that 43% of district pathology laboratories highlightabnormal smear results for GPs and 93% of districts have fail-safe systems to ensure appropriatefollow-up of abnormal smears. Every screening programme should designate an individual as responsiblefor its management. Protocols for the management of women with abnormal results should be drawn up.There are guidelines on fail-safe action28for GPs, clinics, laboratories, the FHSA and the programmemanager.SalÞeld and Sharp29have calculated the demand for colposcopy services based on:
numbe

62 r of women screened
clinical policy for
r of women screened
clinical policy for the referral of women with non-negative smears Gynaecology515 They estimated a demand of 1320 for diagnostic colposcopy per 100000 women. 516Gynaecology 8Outcome measures Gynaecology517 secondary prevention9TargetsHIV/AIDS trends. This represents a reduction from 61 new cases per 100000 population 1990 to no more 518Gynaecology A target of 75 cases of chlamydia infection per 100000 population aged 1515 per 100000 population in 1986 to no more than 12 per 100000. Each district to develop a screening service10Information Gynaecology519 Wales. Data are collected by ICD 9 category. Appendix II details the consultation rates per 10000 personadmissions per 100000 females remain in doubt. The HRG data are patients should be considered and either incorporated into 520Gynaecology Pelvic inßammatory disease and lower geni

63 tal tract infections
More rapid assimila
tal tract infections
More rapid assimilation by the reporting system of national GUM clinic returns is required. The use ofelectronic data capture and transfer systems would speed up reporting, and make the collection andanalysis of the data easier.
Surveillance systems should be instituted for monitoring patients with STDs seen by health serviceproviders other than GUM physicians in order that all local cases are captured.
The current RCGP and HES categories do not allow sensible clinical groupings to be made. Early pregnancy loss
Data on medically managed miscarriage should be collected.Genital tract cancer
Cancer registration data and SMRs can be obtained from cancer registries and are published by OPCSannually. The accuracy of death certiÞcation may be a constraint in using this indicator as coding errors,particularly between the cervix and other pa

64 rts of the uterus are known to occur.
A
rts of the uterus are known to occur.
A future indicator of the screening service could use cancer registry data as registrations of carcinoma ofthe cervix become more accurate and timely. Standardized registration ratios could be used as proxies forincidence. If cancer registration data are used constraints such as the completeness and accuracy ofascertainment292and the length of time to publication of the data by OPCS need to be considered.Because of the small number of events in each district or region the 95% conÞdence intervals of the SMR orstandardized registration rates will be wide. Consequently interpretation of these data has to be cautious.The SMR for carcinoma of the cervix varies signiÞcantly between regions which may reßect differences inthe risk of cervical cancer incidence and/or case fatality. Interpretation of the SMR should be in conj

65 unctionwith data on risk, such as regist
unctionwith data on risk, such as registration rates. The SMR may also be affected by effectiveness of management ofabnormal smears and invasive disease in a district or region.
The Health of the NationKey Area Handbookon cancer recommends three-yearly registration rates beestimated. For carcinoma in situ(ICD 233.1) there is known to be variability between regions andwhether this is artefactual is not known.
Returns and annual analyses of the number of smears, number of abnormal smears are reported in theDH(KC53 and 61) data.The Health of the Nation Key Area Handbookon cancer recommends the following information be preparedannually on the women aged 20Ð64.
The proportions of women adequately tested in past systems, ceased from recall, with no computerrecord, presumed non-responders and waiting times for cytology.
Currently the cancer registries use a g

66 eneric stage for all sites. The FIGO gyn
eneric stage for all sites. The FIGO gynaecology staging schemeshould be adopted for these sites or algorithms developed to convert them accurately. Gynaecology521 11Research 522Gynaecology clinics for menstrual disorders should be undertaken. Gynaecology523 secondary prevention 524Gynaecology Appendix IDiagnostic codes179Malignant neoplasm of uterus, part speci180Malignant neoplasm of cervix uteri181Malignant neoplasm of placenta182Malignant neoplasm of body of uterus183Malignant neoplasm of ovary and other uterine adnexa184Malignant neoplasm of other and unspeci218Uterine leiomyoma219Other benign neoplasm of uterus220Benign neoplasm of ovary221Benign neoplasm of other female genital organs256Ovarian dysfunction614In615In616In617Endometriosis618Genital prolapse619Fistulae involving female genital tract620Non-in621Disorders of uterus, not elsewhere cl

67 assi622Non-in623Non-in624Non-in625Pain a
assi622Non-in623Non-in624Non-in625Pain and other symptoms associated with female genital organs626Disorders of menstruation and other abnormal bleeding from female genital tract627Menopausal and postmenopausal disorders628Infertility, female629Other disorders of female genital organs630Hydatidiform mole631Other abnormal product of conception632Missed abortion633Ectopic pregnancy634Spontaneous abortion635Legally induced abortion636Illegally induced abortion637Unspeci638Failed attempted abortion639Complications following abortion and ectopic and molar pregnancies Gynaecology525 Medical partitioning69 and/or ccYes366No367Menstrual and other female reproductive system diagnoses369 Surgical partitioningPelvic evisceration, radical hysterectomy and radical vulvectomy353Ovarian and adnexal malignancy357Other malignancyYes35469 and/or ccNo355Non-malignancyYes3

68 5869 and/or ccNo359Female reproductive s
5869 and/or ccNo359Female reproductive system, reconstructive procedures356Vagina, cervix and vulva procedures360Laparoscopy and incisional tubal interruption361D&C, conization and radio-implantPrinciple diagnosis malignancyYes363No364Endoscopic tubal interruption362Other female reproductive system OR procedures365 procedure377no procedure376Ectopic pregnancy378Threatened abortion379HRGHRG text lablem01Minor Procedures Vulva/Labiam02Minor Procedures Vagina/Perineumm03Minor Procedures Cervix/Uterusm04Minor Procedures Uterus/Adnexaem05Intermediate Procedures Vulva/Labiam06Intermediate Procedures Vagina/Perineum 526Gynaecology m07Intermediate Procedures Vagina/Uterusm08Intermediate Procedures Uterus/Adnexaem09Major Procedures Vulva/Labiam10Major Procedures Uterus/Perineumm11Major Procedures Uterus/Adnexaem12Complex Major Procedures Vulva/Labiam13Complex Ma

69 jor Procedures Uterusm14Threatened Abort
jor Procedures Uterusm14Threatened Abortionm15Spontaneous Abortionm16Ectopic Pregnancym17Termination of Pregnancym18Contraceptive Care/Sterilizationm19Infertilitym20Non-inm21Inm22Non-inm23Ovary/Tube/Pelvic Inm24Non-inm25Fibroids/Menstrual Disordes/Endometriosism26Genital Prolapsem27Carcinoma of Uterusm28Carcinoma of Ovary m29Carcinoma of Ovary m30Other Gynaecological Malignancy m31Other Gynaecological Malignancy m32Other Gynaecological ConditionsP.LOWER FEMALE GENITAL TRACTVulva and female perineum (P01–P13)p01Operations on clitoris p03Operations on Bartholin glandp05Excision of vulvap06Extirpation of lesion of vulvap07Repair of vulva p09Other operations on vulva p11Extirpation of lesion of female perineum p13Other operations on female perineum Vagina (P14–P31)p14Incision of introitus of vagina p15Other operations on introitus of vagina p17Excision of v

70 agina p18Other obliteration of vaginap20
agina p18Other obliteration of vaginap20Extirpation of lesion of vagina p21Plastic operations on vagina p22Repair of prolapse of vagina and amputation of cervix uteri Gynaecology527 p23Other repair of prolapse of vagina p24Repair of vault of vagina p25Other repair of vagina p26Introduction of supporting pessary into vagina p27Exploration of vagina p29Other operations on vagina p31Operations on pouch of Douglas Q.UPPER FEMALE GENITAL TRACTQ01Excision of cervix uteri Q02Destruction of lesion of cervix uteri Q03Biopsy of cervix uteri Q05Other operations on cervix uteri Q07Abdominal excision of uterus Q08Vaginal excision of uterusQ09Other open operations on uterusQ10Curettage of uterus Q11Other evacuation of contents of uterus Q12Intrauterine contraceptive device Q13Introduction of gamete into uterine cavity Q14Introduction of abortifacient into uterine ca

71 vity Q15Introduction of other substance
vity Q15Introduction of other substance into uterine cavity Q16Other vaginal operations on uterus Q17Therapeutic endoscopic operations on uterus Q18Diagnostic endoscopic examination of uterus Q20Other operations on uterus Q22Bilateral excision of adnexa of uterus Q23Unilateral excision of adnexa of uterus Q24Other excision of adnexa of uterus Q25Partial excision of fallopian tube Q26Placement of prosthesis in fallopian tube Q27Open bilateral occlusion of fallopian tubes Q28Other open occlusion of fallopian tube Q29Open reversal of female sterilization Q30Other repair of fallopian tube Q31Incision of fallopian tube Q32Operations on Q34Other open operations on fallopian tube Q35Endoscopic bilateral occlusion of fallopian tubes Q36Other endoscopic occlusion of fallopian tubeQ37Endoscopic reversal of female sterilization Q38Other therapeutic endoscopic oper

72 ations on fallopian tube Q39Diagnostic e
ations on fallopian tube Q39Diagnostic endoscopic examination of fallopian tube Q41Other operations on fallopian tube 528Gynaecology Q43Partial excision of ovary Q44Open destruction of lesion of ovaryQ45Repair of ovary Q47Other open operations on ovary Q48Oocyte recovery Q49Therapeutic endoscopic operations on ovary Q50Diagnostic endoscopic examination of ovary Q52Operations on broad ligament of uterus Q54Operations on other ligament of uterus Q55Other examination of female genital tract Q56Other operations on female genital tract Gynaecology529 Appendix IIMorbidity survey in general practice 1991/92Patients consulting and consultation rates per 10000 female personConditionICDPatients consulting per10000 person10000 personCandidiasis112521690Trichomoniasis13167 Uterus, unspecied17911 Cervix120312 Body uterus18225 Ovary + adnexae183414Uterine leiomyoma

73 ta2181316 Ovary22012 Other22111616212198
ta2181316 Ovary22012 Other22111616212198Endometriosis6171124Genital prolapse61845716209146215662222266236478 530Gynaecology ConditionICDPatients consulting per10000 person10000 person62456625278394626449676627328583Infertility6283157Early pregnancy loss6306395369 Gynaecology531 Appendix IIIHospital episode statistics: 532Gynaecology Number of women per 100000 female population with gynaecological100000179Malignant neoplasm of uterus, part unspecied8464180Malignant neoplasm of cervix uteri8769344181Malignant neoplasm of placenta3764182Malignant neoplasm of body of uterus630427183Malignant neoplasm of ovary and other uterine adnexa2001086184Malignant neoplasm of other and unspeci240710218Uterine leiomyoma25825111219Other benign neoplasm of uterus5913220Benign neoplasm of ovary374216221Benign neoplasm of other female genital organs6253256Ovarian dysfuncti

74 on401617614In2023887615Inammatory diseas
on401617614In2023887615Inammatory diseases of uterus, except cervix13376616Inammatory disease of cervix, vagina and vulva1506365617Endometriosis1443262618Genital prolapse31961137619Fistulae involving female genital tract13816620Non-in1777976621Disorders of uterus, not elsewhere classied1127548622Non-inammatory disorders of cervix41119176623Non-inammatory disorders of vagina1722374624Non-inammatory disorders of vulva and perineum630227625Pain and other symptoms associated with female genital39448170626Disorders of menstruation and other abnormal bleeding105812455 Gynaecology533 100000627Menopausal and postmenopausal disorders30757132628Infertility, female27099117629Other disorders of female genital organs226210 1967 630Hydatidiform mole63067911701925031631Other abnormal product of conception632Missed abortion633Ectopic pregnancy634Spontaneous abortion635

75 Legally induced abortion636Illegally ind
Legally induced abortion636Illegally induced abortion637Unspeci638Failed attempted abortion639Complications following abortion and ectopic and molarTotal6998 OA7970DC790OA+DC=8769BD65367mean LOS=8.2median LOS=4OA6613DC537OA+DC=7150BD60226mean LOS=9.1median LOS=6OA22397DC4019OA+DC=26416(98% 534Gynaecology BD155150mean LOS=6.9median LOS=6OA3712DC30OA+DC=3742BD30277mean LOS=8.2median LOS=7OA231653DC151835OA+DC=383488BD981353OA2249DC356OA+DC=2605BD13432mean LOS=6median LOS=6OA14420DC3075OA+DC=17495BD51723mean LOS=3.6median LOS=2OA10945DC5455OA+DC=16400BD26744mean LOS=2.4median LOS=1OA30842DC1119OA+DC=31961BD241826mean LOS=7.8median LOS=6 Gynaecology535 OA45924DC32220OA+DC=78144BD203407mean LOS=4.4median LOS=3OA9738DC17361OA+DC=27099BD17028mean LOS=1.8median LOS=1OA1079701DC90491BD3284836mean LOS=1.8median LOS=1Total 19577 P.LOWER FEMALE GENITAL TRACTp01Ope

76 rations on clitoris 117p03Operations on
rations on clitoris 117p03Operations on Bartholin gland5367p05Excision of vulva5093p06Extirpation of lesion of vulva1485p07Repair of vulva 180p09Other operations on vulva 6392p11Extirpation of lesion of female perineum 660p13Other operations on female perineum 2569p14Incision of introitus of vagina 304p15Other operations on introitus of vagina 810p17Excision of vagina 144p18Other obliteration of vagina75p19Excision of band of vagina201p20Extirpation of lesion of vagina 2873 536Gynaecology p21Plastic operations on vagina 204p22Repair of prolapse of vagina and amputation of cervix uteri 1308p23Other repair of prolapse of vagina 19940p24Repair of vault of vagina 505p25Other repair of vagina 739p26Introduction of supporting pessary into vagina 848p27Exploration of vagina 20538p29Other operations on vagina 1758p31Operations on pouch of Douglas 296Q.UPPER FEM

77 ALE GENITAL TRACTQ01Excision of cervix u
ALE GENITAL TRACTQ01Excision of cervix uteri 9416Q02Destruction of lesion of cervix uteri 19622Q03Biopsy of cervix uteri 23031Q05Other operations on cervix uteri 1447Q07Abdominal excision of uterus 59376Q08Vaginal excision of uterus14141Q09Other open operations on uterus1507Q10Curettage of uterus 166146Q11Other evacuation of contents of uterus 154222Q12Intrauterine contraceptive device 3404Q13Introduction of gamete into uterine cavity 1128Q14Introduction of abortifacient into uterine cavity 7223Q15Introduction of other substance into uterine cavity 1298Q16Other vaginal operations on uterus 430Q17Therapeutic endoscopic operations on uterus 9945Q18Diagnostic endoscopic examination of uterus 21853Q20Other operations on uterus 1166Q22Bilateral excision of adnexa of uterus 2650Q23Unilateral excision of adnexa of uterus 8281Q24Other excision of adnexa of uter

78 us 1867Q25Partial excision of fallopian
us 1867Q25Partial excision of fallopian tube 1448Q26Placement of prosthesis in fallopian tube 22Q27Open bilateral occlusion of fallopian tubes 1856Q28Other open occlusion of fallopian tube 136Q29Open reversal of female sterilization 1138Q30Other repair of fallopian tube 1409Q31Incision of fallopian tube 1085Q32Operations on Q34Other open operations on fallopian tube 485Q35Endoscopic bilateral occlusion of fallopian tubes 50969Q36Other endoscopic occlusion of fallopian tube326Q37Endoscopic reversal of female sterilization 433Q38Other therapeutic endoscopic operations on fallopian tube 1087Q39Diagnostic endoscopic examination of fallopian tube 7169Q41Other operations on fallopian tube 12827 Gynaecology537 Q43Partial excision of ovary 3372Q44Open destruction of lesion of ovary143Q45Repair of ovary 158Q47Other open operations on ovary 752Q48Oocyte recovery

79 2039Q49Therapeutic endoscopic operations
2039Q49Therapeutic endoscopic operations on ovary 3629Q50Diagnostic endoscopic examination of ovary 1198Q52Operations on broad ligament of uterus 144Q54Operations on other ligament of uterus 617Q55Other examination of female genital tract 5967Q56Other operations on female genital tract 53 PLower genital tractOA42558DC29848BD223571PAVulva and female perineumOA13651DC8212BD43835PA1Operations on Bartholin glandOA4359DC1008BD5250PBVaginaOA28907DC21636BD179736PB1Repair of prolapse of vaginaOA21232DC16BD152978QUpper genital tractOA307069DC239718BD973100QAUterusOA247541DC187814BD775486 538Gynaecology QA1Operations on cervix uteriOA15659DC37857BD26467QA2Excision of uterusOA73465DC52BD527945QA3Evacuation of contents of uterusOA133920DC126448BD171790QBFallopian tubeOA48329DC45031BD149341QB1Excision of adnexa of uterusOA12782DC16BD80617QB2Open occlusion of fallopi

80 an tubeOA1789DC203BD5501QB3Endoscopic oc
an tubeOA1789DC203BD5501QB3Endoscopic occlusion of fallopian tubeOA19563DC31732BD22284QB4Other endoscopic operations on fallopian tubeOA4466DC4223BD8463QCOvary and broad ligamentOA11199DC6873BD48273RFemale genital tract associated with pregnancy, childbirth and puerperiumOA613740DC852BD2126725 Gynaecology539 meanmedianMalignant neoplasm of cervix uteri19.113ed20.914Benign neoplasm of uterus95.460Benign neoplasm of ovary40.421Salpingitis and oophoritis99.460ammatory disease of pelvic cellular tissue and peritoneum106.462ammatory diseases of uterus, vagina and vulva67.140Utero-vaginal prolapse146.6105Menstrual disorders90.556Infertility female101.364Total cases all causes including gynaecology90.641 P.LOWER FEMALE GENITAL TRACTmeanmedianRepair of prolapse of vagina157.1117Excision of uterus107.169Evacuation of contents of uterus33.11196.454 female reprod

81 uctive systemHRGLabelN cases% Chap.% day
uctive systemHRGLabelN cases% Chap.% day% Emerg.MeanStd dayQ1MedQ3Trim Pt.% Trimm01Min Pxs Vulva/Labia14110.2062.72.31.10.811239.5m02Min Pxs Vag/Perineum129551.8745.814.11.30.8112310.0m03Min Pxs Cerv/Uterus422176.1086.61.11.01.001252.4m04Min Pxs Uterus/Adnexae25767537.2349.328.51.10.811133.6m05Inter Pxs Vulva/Labia148382.1434.133.21.30.711237.5m06Inter Pxs Vag/Perineum48070.6937.58.82.31.912387.1m07Inter Pxs Cerv/Uterus295034.2664.91.81.30.911235.9m08Inter Pxs Uterus/Adnexae10525615.2157.32.41.10.811235.8m09Maj Pxs Vulva/Labia11150.1623.67.412.010.521018474.5m10Maj Pxs Vag/Perineum224883.250.51.06.62.0568125.5m11Maj Pxs Uterus/Adnexae8603412.431.012.76.11.8567106.1m12Comp Maj Pxs Vulva/Labia690.010.02.922.79.8152132562.9m13Comp Maj Pxs Uterus/Adnexae5320.080.24.110.23.481012209.0m14Threatened abortion250793.623.882.51.01.101252.5m15Spontaneous Abortion1

82 08991.572.685.60.70.701127.9m16Ectopic P
08991.572.685.60.70.701127.9m16Ectopic Pregnancy5600.080.293.91.61.901273.9m17Termination of Pregnancy21460.3149.811.71.01.101251.3m18Contracept Care/Steriln1260.0231.720.62.02.2014101.2m19Infertility12500.1847.815.30.50.600128.3m20Non InDis of Vulva/Vag80331.164.577.61.01.101154.3m21InDis of Vulva/Vag/Cerv14900.227.379.81.01.201159.6m22Non InDis of Cerv14180.2048.313.00.91.101159.8m23Ovary/Tube/Pelvic In70181.010.596.11.91.512364.4m24Non InDis of Tube/Ovary43130.627.181.41.71.511266.9m25Fibs/Menst Disds/Endsis139252.019.863.91.11.201254.2m26Genital Prolapse27780.4015.911.12.22.6013107.7m27Carcinoma of Uterus12300.188.940.56.77.02410297.3m28Carcinoma of Ovary 69 or w cc40190.5826.335.85.15.7138237.0m29Carcinoma of Ovary 70 w/o cc102881.4931.718.01.61.4112612.2m30Oth Gyn Malig 64 or w cc22010.325.645.28.98.72613346.6m31Oth Gyn Malig 65 w/o cc33890.4918.5

83 29.32.92.51241112.0m32Other Gynae Condns
29.32.92.51241112.0m32Other Gynae Condns130611.8916.664.31.21.201254.8 Gynaecology541 Appendix IVOutlet of bladder operations in femalesM51Combined abdominal and vaginal operations to support outlet of female bladder151620M52Abdominal operations to support outlet of female bladder456161M53Vaginal operations to support outlet of female bladder3466M55Other operations on outlet of female bladder961M56Therapeutic operations on outlet of female bladder2654M58Other operations on outlet of female bladder7009 542Gynaecology Appendix VStratiLEVEL 1DIAGNOSTIC LAPAROSCOPYLEVEL 2MINOR LAPAROSCOPIC PROCEDURES Revised AFS Stage ILEVEL 3MORE EXTENSIVE PROCEDURES REQUIRING ADDITIONAL TRAINING Revised AFS Stage II and IIILEVEL 4EXTENSIVE ENDOSCOPIC PROCEDURES REQUIRING SUBSPECIALIST ORLEVEL 1DIAGNOSTIC PROCEDURES plus target biopsyLEVEL 2MINOR OPERATIVE PROCEDURESLEVEL

84 3MORE COMPLEX OPERATIVE PROCEDURES REQUI
3MORE COMPLEX OPERATIVE PROCEDURES REQUIRING ADDITIONAL Gynaecology543 Appendix VICervical screening Health of the Nationa)health promotion activitiesb)build alliances with other agencies such as the network and HEAc)purchasing cervical screening services of high qualityd)availability of services to eligible populatione)maximize attendance for screeningf)set targets for purchasing high quality diagnostic, therapeutic and support services for women 544Gynaecology Appendix VIIExpert Advisory Committee on Cancer. (A1Access to uniformly high quality of care in the community or hospital to ensure maximum2Promotion of early recognition of symptoms and availability of screening.3Clear information and assistance regarding treatment options and outcomes available.4Services to be patient centred.5Primary care team is central and continuing element in cancer care

85 and communication6Psychosocial aspects o
and communication6Psychosocial aspects of cancer care should be considered at all stages.7Cancer registration and careful monitoring of treatment and outcomes is essential.1Primary care as focus of care.2Designated cancer units in DGHs to manage commoner cancers (which probably do not3Designated cancer centres to manage all cancers, including common cancers and less common1Need to develop arrangements for the close integration of primary and secondary care,2Appropriate training of surgeons (the RCOG subspecialty training scheme for gynaecological3Multi-disciplinary consultation and management requires a minimum of 4Chemotherapy if it is to be given in a cancer unit should only be if appropriate facilities and Gynaecology545 A cancer centre should serve a population of at least 1000000 and no less than 750000. paediatric and adolescent cancer services 54

86 6Gynaecology Appendix VIIIGlossary of te
6Gynaecology Appendix VIIIGlossary of termsAIDartiCINcervical intraepithelial neoplasiaD&Cdilatation and curettageDRGdiagnostic related groupsDUBdysfunctional uterine bleedingERPCevacuation of the retained products of conceptionGIFTgamete intra-fallopian transferGUMgenitourinary medicineHEShospital episode statisticsHIVhuman immunodeHRThormone replacement therapyHRGhealth care resource groupingHSGhysterosalpingogramICDinternational classiIUCDintra-uterine contraceptive deviceLAVHlaparoscopically assisted vaginal hysterectomyLLETZlarge loop excision of the transformation zoneMASminimal access surgeryPID pelvic inPMSpremenstrual syndromeRCOGRoyal College of Obstetricians and GynaecolgistsTAHtotal abdominal hysterectomyTCREtranscervical resection of the endometrium Gynaecology547 1Ashton JR, Marchbank A, Mawle P 2Human Fertilisation Embryology Authority. 3

87 Taylor-Robinson D. 4Ripa T. Epidemiologi
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