Transcript Women`s Health Procedures in FM Skills Transfer Workshop

Women’s Health
Procedures in FM
Skills Transfer Workshop
Drs. Christiane Kuntz, Cathy Caron,
Emily Brecher, Ruth Morris
FMR Academic Day Dec. 4, 2015
Faculty/Presenter Disclosure
• Faculty: Dr. Christiane Kuntz/Dr. Cathy Caron/Dr.
Ruth Morris/Dr. Emily Brecher
• Program: Academic Day – Dec. 4, 2015
• Relationships with commercial interests:
–
–
–
–
Grants/Research Support: none
Speakers Bureau/Honoraria: see next slides
Consulting Fees: none
Other: none
Disclosure of Commercial
Support
• This program has received no financial support through any
commercial organization.
• This program has received no in-kind support from any
commercial organization.
• Potential for conflict(s) of interest:
– none
Mitigating Potential Bias
• none
Origin of workshop
Funding from Women’s Health Council
 Goal: decrease hysterectomy rate in
Ontario
 Collaboration with Ontario College of
Family Physicians and academic
gynecologists

ICES data on hysterectomy
One of the most commonly performed surgical
procedures in Ontario: 20,000/yr
 Variation across province moderately large: from
932/100,000 in Nipissing/Temiskaming to
372/100,000 in metropolitan Toronto
 Age-adjusted rates fell decade ’85-’95: 27%
relative decline but the highest rates in ’94-’95
remained in women 35 to 49

ICES:Variations in Selected Surgical
Procedures and Medical Diagnoses by
Year and Region
Objectives of Workshop

At the end of this workshop, the participant will
be able to: (1) Describe to a colleague the
indications and contraindications to perform a
pelvic exam, Pap smear, endometrial biopsy,
Mirena IUS insertion and pessary fitting;
(2) List to a colleague the steps involved in the
preparation for, the performance of and the
follow-up for these procedures; (3) Follow the
steps for each procedure on a bench model;
(4) Display sensitivity to the patient in the
performance of the above procedures.
Benign Uterine Conditions

Fibroids
 Abnormal Uterine Bleeding
 Endometriosis
 Chronic Pelvic Pain
 Pelvic Organ Prolapse
Outline of Procedures
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Pelvic Exam, including pap/swabs
 Endometrial Biopsy
 Insertion of Levonorgestrel Intra-Uterine
System (LNG-IUS/ Mirena)
 Assessment of Pelvic Organ Prolapse
 Pessary Fitting and Maintenance
Normal Gyne Exam
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External inspection
– Lesions, atrophy, change in anatomy
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Speculum exam
– PAP and swabs, atrophy, lesions
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Bimanual exam
– Uterus, ovaries, masses, mobility, tenderness
Tricks of the Trade
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Set the mood
Prepare the equipment beforehand
Incorporate a trainee (if applicable)
Reassure the anxious patient
Use presence of third party for reassurance
Ask if prior traumatic experience, difficulty locating cervix,
particular anatomic variation
Optimize position for exam
Talk to the patient through the procedure and involve them
in the process
Cue on body language
Tricks of the Trade
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Select appropriate size/length speculum
 WARM the speculum (if metal)
 USE LUBRICANT GEL
 TAKE YOUR TIME
 BE GENTLE
 RESPECT YOUR PATIENT’S STYLE OF
INTERACTION; use humor carefully
PAP

Who to screen
 Third party presence
 Lubrication of speculum
 Order of samples
 Method –slide or liquid based, brush…
 HPV-DNA testing
 Questions? Tips?
Ontario 2012 PAP Guidelines
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Start screening age 21 if ever sexually active
If normal, screen q 3 years
If no T zone, no need to re-sample
Immunocompromised women – screen annually
Hx of dysplasia, screening interval at discretion
of primary health care provider – more often?
May stop screening age 70 if 3 N Paps in last 10
years
Endometrial Biopsy
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Indications
– Pre-menopausal
 Any persistent change in menstrual cycle, frequency,
duration, or flow
 Breakthrough bleeding
– Post-menopausal
 Vaginal bleeding > 12 months after last period
 Bleeding > 6-12 months after initiating HT
Assess Risk Endometrial Cancer
 Obesity (weight > 90 kg/200 lbs)
 Age
or BMI > 40
> 40
 Diabetes type II
 Anovulatory cycle / PCOS
 Tamoxifen
 Family history endometrial or colon CA
Post-Menopausal bleeding
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Atrophic Vaginitis
 Endometrial Polyp
 Endometrial Hyperplasia
 Endometrial Cancer
 Hormonal effect
 Cervical Cancer
 Other
Source: Karlsson et al 1995
59%
12%
10%
10%
7%
2%
<1%
FIBROIDS
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Benign smooth muscle tumors of uterus
 Asymptomatic do not require treatment
 Symptoms: AUB, anemia, pain/pressure,
bowel/bladder dysfunction, rarely infertility
 Physical exam and ultrasound
 Must SAMPLE ENDOMETRIUM if AUB
and risk factors for cancer present.
Post-menopausal bleeding
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Newly on HT, wait 6-12 months
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Evaluate Endometrium/Uterine cavity
– Either endometrial biopsy, transvaginal ultrasound or
both can be done to initially assess the endometrium
– Can base choice of first investigation upon patient
preference, physician comfort with procedure, U/S
availability
Medications for AUB
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NSAIDS
 Tranexamic Acid (Cyklokapron) - $1/tablet
 OCP
 Mirena - $400 (2014 figures)
 Progestins (oral, IM)
 GNrH agonist
 Ulipristal
AUB Management
Medications for AUB
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Ulipristal
Selective progesterone receptor modulator
(think SPRM)
 Side effects – abdominal pain, irregular
bleeding/amenorrhea, headaches, nausea
 metabolized by CYP3A4; avoid in women with
severe liver disease, lactation, < age 18
 could interact with substrates of CYP3A4, like
rifampicin, phenytoin, St John's wort,
carbamazepine, ritonavir, hormonal
contraceptives and progestogens such as
levonorgestrel, glucocorticoids
AUB Management
Medications for AUB
As a SPRM, ulipristal acetate has partial
agonistic as well as antagonistic effects on
the progesterone receptor
 binds to the glucocorticoid receptor
 has no relevant affinity to the estrogen,
androgen and mineralocorticoid receptors
 mechanism might consist of blocking or
delaying ovulation and of delaying the
maturation of the endometrium
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AUB Management
Medications for AUB
Used for emergency contraception in over
50 countries at a dose of 30 mg tablet
within 120 hours (5 days) after
unprotected sex or contraceptive failure
 has been shown to prevent about 60% of
expected pregnancies (more pregnancies
than emergency contraception with
levonorgestrel
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AUB Management
Medications for AUB
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Ulipristal acetate
pre-operative treatment of uterine fibroids in
reproductive age women 5 mg/day for 3 months
effectively controlled excessive bleeding due to uterine
fibroids and reduced the size of the fibroids
 2 interrupted 3-month Rx courses of ulipristal acetate 10
mg resulted in amenorrhea at the end of the first
treatment course in 79.5%, at the end of the second
course in 88.5% of subjects
 fibroid volume reduction observed during the first
treatment course (−41.9%) was maintained during the
second one (−43.7%)
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Endometrial Biopsy
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Purpose is to evaluate the endometrial
lining
– Cancer
– Pre-cancerous (hyperplasia)
– Normal endometrial growth
 Infertility: luteal phase defect
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Small tube inserted through the os
 Office procedure
Endometrial Biopsy
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Sensitivity to detect abnormalities 81-96 %
– Comparable to dilatation + curettage
– Less reliable than hysteroscopy
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Adequate sample obtained > 85%
 OHIP billing: Z770 & E542
Tricks of the Trade
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An endometrial biopsy is a “clean” procedure
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Prior to biopsy
– Have patient insert 2 X 200 micrograms misoprostol tablets per vagina
4-12 hours before procedure
*** Warning: this is an off-label use and can rarely cause severe
cramping, diarrhea, nausea/vomiting, chills, bleeding
– OR
– insert an osmotic laminaria 3 mm size 4-6 hours prior to biopsy
Tricks of the Trade
 At time of biopsy
- Biopsy Sampler/Pipelle
-place in freezer to stiffen
-lubricate tip with sterile topical anesthetic
-xylocaine jelly 2% (Urojet) applied into cervix
- Os Finder/Cervical Dilators
- Tenaculum to steady cervix and give traction
Interpreting an Endometrial Biopsy
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Normal
– Symptoms resolve→follow
– Symptoms persist→transvaginal U/S
Unable to perform/inadequate sample
– Repeat (see tips)
– Transvaginal U/S
Hyperplasia without atypia
– Provera 10mg od/ Prometrium 200 mg po/pv for 30 days
or cyclic 12-14 days x 3-6 months
– Repeat biopsy 3-6 months
Hyperplasia with atypia, cancer→refer
Endometrial Biopsy
Hands on demonstration
Mirena IUS
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T-shaped device which releases 20 ug/day of
levonorgestrel locally in the uterine cavity
 Inserted in the office, similar to regular IUD
 Lasts 5 years
 device covered on ODB
 OHIP billing: G378 & E430
Usage of Mirena
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Indication: contraception
 Also used for:
– Abnormal uterine bleeding
– Endometriosis
– Fibroids
– Endometrial Hyperplasia
Mirena: side effects
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Breakthrough bleeding up to 6 months
– followed by amenorrhea in 70 % by one year
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Mild cramps upon insertion
 Possible progesterone side effects from
systemic absorption in first few weeks
 Expulsion, perforation (1/1000)
Tricks of the Trade
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A Mirena IUS insertion is a “sterile” procedure
Do bimanual exam if uncertain of uterine position
Do U/S to assess length of uterus if nullip (5 cm)
To prepare the cervix, use same tricks as for biopsy
Assess ability to enter uterine cavity with sound
before opening IUS package
Use pipelle to sound uterus if biopsy is needed
Leave strings fairly long (3-4 cm) and tuck in culde-sac
Tricks of the Trade
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Insert early in cycle (days 4-8) to reduce spotting/bleeding
Consider priming with progesterone or OCP x 1-2 months if
severe menorrhagia
 Warn patient about potential side-effects to improve
compliance
 Ovulation will continue normally in most ♀
 Immediately effective as contraceptive, and immediately
reversible
 May get free replacement if dropped, expulsed, or causing
pain
 No need to remove if endometritis; treat with Mirena in-situ
 May do PAP, SIS, and endo biopsy with Mirena in-situ
Mirena IUS
Hands on demonstration
Pelvic Organ
Prolapse
Pelvic Floor Defects
 Cystocele
and Urethrocele
 Rectocele and Enterocele
– Tears or defects in the rectovaginal septum
 Uterine and Vaginal Prolapse
– Break in attachments of the cardinal and
uterosacral ligaments to the cervical ring
– Vaginal vault prolapse may also occur after
hysterectomy
Predisposing Factors
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Vaginal birth
– Prolonged second stage, large fetus, instrumental delivery, trauma
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Aging and genetic factors
– Neuromuscular deterioration, chronic illness, collagen deficiency
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Estrogen deficiency
– Lower genital tract rich in estrogen receptors; loss of estrogen causes
decreased blood flow, loss of tissue integrity
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Smoking
– Anti-estrogen properties, loss of collagen, elasticity, tissue support
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Others
– Constipation, obesity, chronic cough, heavy lifting
U PROLAPSE
U PROLAPSE
Presenting complaints
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Urinary frequency
Urinary retention
Bulge in vagina
Pelvic pressure/sense of GU fullness
Incontinence urine/stool
Constipation
Dyspareunia
Backache
Need to digitate to evacuate
Vaginal bleeding/discharge (from mucosal erosion)
Standard Assessment for A
Pessary Fitting
Psychosocial Status
 Chief Complaint
 Lifestyle Patterns
 Medical History
 Surgical History
 Physical Assessment
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Physical Exam
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Observe
 Valsalva (bearing down)
– Beware of incontinence !!!
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Speculum
– Remove one blade
– Examine anterior area for cystocoele (with Valsalva)
– Examine posterior area for rectocoele (with Valsalva)
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Digital exam with Valsalva to assess uterine prolapse
 Reduce cystocoele to rule out incontinence
 Have patient stand if not obvious
CYSTOCELE
CYSTOCELE
Pelvic Organ Prolapse
Distention Cystocele
RECTOCELE
RECTOCELE
UTERINE AND VAGINAL
PROLAPSE
UTERINE AND VAGINAL PROLAPSE
Pelvic Prolapse Staging
Stage
Leading edge of Prolapse: Location
of the Most Distal Point of the
Anterior or Posterior Vaginal Wall
(any points Aa, Ap, Ba, Bp)
Leading Edge of Prolapse: Location
of Apex of Vagina or Cervix
(Value of Point C or D)
0
No prolapse: All points are 3 cm
above the hymen (value=-3)
No prolapse: Apex of cervix is at a
position above the hymen that
equals to or is within +/- 2 cm of
vaginal length (value </= (tvl-2))
I
All points are more than 1 cm above
hymen (value<-1)
II
Maximal prolapse point protrudes
to or beyond 1 cm above hymen but
not more than 1 cm below hymen
(value >-1 to <+1)
III
Maximal prolapse point protrudes
beyond 1 cm above hymen but less
than 2 cm less than the total vaginal
length. (value >+1 but <+(tvl-2))
IV
Maximal prolapse point protrudes
the length of the vagina (2 cm)
beyond the hymen. Complete
eversion of the vagina +/- cervix
([value >/= + [tvl-2])
tvl=total vaginal length
TREATMENT
Treatment
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Asymptomatic: no treatment
 Lifestyle
– weight loss, smoking cessation, treat constipation
 Kegels (20-50 x 3/day)
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Biofeedback, electrical stimulation, pelvic physio
 Vaginal estrogen
 Pessary
 Surgery
– Success rate 65-90%, re-operation rate 15-30%
Pessary
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Intra-vaginal silicone (latex free) device
 Different types
 Fit by trial and error with a set of fitting rings
 Start simply in order to promote eventual
patient self-care
 If vaginal dryness and atrophy present, best
to pre-medicate with vaginal estrogen for 1-2
months before fitting and for ongoing use
Pessary in place
Types of pessaries
Various types of pessaries: (A)
Ring, (B) Shaatz, (C) Gellhorn,
(D) Gellhorn, (E) Ring with
support, (F) Gellhorn, (G)
Risser, (H) Smith, (I) Tandem
cube, (J) Cube, (K) Hodge with
knob, (L) Hodge, (M) Gehrung,
(N) Incontinence dish with
support, (O) Donut, (P)
Incontinence ring, (Q)
Incontinence dish, (R) Hodge
with support, (S) Inflatoball
(latex).
Pessary Fitting Principles
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Start simply because ideally the goal is to
promote patient self care.
Determine your sizing.
Lubricate the leading edge of the fitting ring.
Fold the fitting ring in half and insert while
folded.
Minimize urethral & introital trauma when
inserting the fitting ring by placing the force
more posteriorly on the vagina during insertion.
Confirm the correct placement of the pessary
fitting ring.
–If able, the patient is taught how to remove
and insert the pessary by using the fitting ring.
– The role and use of Replens and hormonal
therapy (estrogen ung, Vagifem, or Estring) are
reinforced with the patient.
– The patient doing self care is encouraged to
take the pessary out at least once a week to rest
the vagina. Some patients may not be able to
manage self care and should be seen q3 months
to receive professional care.
–The patient is instructed to clean the pessary
with dish soap and water.
–The patient is informed about the signs and
symptoms to report to the health care
professional which would include:
 Bleeding
 Foul-smelling, green discharge
 Pain
 Difficulty voiding or defecating
Pessary Care Follow-up Visits
Initial or new pessary fittings (self-care) are
given follow-up visits in the clinic:
-two to three weeks after initial
fitting
-one three month visit
-one six month visit
 Patients who cannot do their own care follow
the same times but will be seen every three
months after the initial two to three week visit.
 Pessaries can be used for 5 years before
needing replacement.
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Pessary Care
If an erosion is found on vaginal
examination on a follow-up visit, the
pessary should be removed for 1-2 weeks
and the patient instructed to use
Aminocerv (if available) which promotes
mucosal healing
 F.U. patient 2 weeks later to check for
healing and to reassess whether the
pessary still fits the patient appropriately
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Pessary Use
This device can remain in place during
intercourse or removed and replaced
afterwards.
 Intimate partners can assist in the
removal, care and replacement of the
pessary
 If patient into DIY, can try “Uresta” –
order on line; 3 sizes – 3, 4, 5 – looks like
a soother or plug – cost $250

Pessary Fitting
Hands on demonstration
THANK EWE !