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  • Through the hysteroscope: Reflections of a gynaecologist

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    Summary

    At Patient Safety Learning, we’ve been working with others to understand the issues surrounding painful hysteroscopies.

    In this interview, we talk to Obstetrics and Gynaecology consultant, Saira Sundar, about the process. She offers her clinical insight and highlights some of the challenges involved when it comes to managing pain during hysteroscopies.  

    Saira also offers advice to colleagues and patients seeking to reduce anxiety and improve the patient experience.

    Questions & Answers

    Can you tell us a bit about yourself and your role?

    I've worked in Obstetrics and Gynaecology for over a decade, and it’s hard to describe the privilege of doing this job – supporting women through some of the most pivotal moments in their lives. What's great about being a healthcare professional, is you never have to justify the meaning of your work to yourself. My mother's one of that generation of West Indian nurses, who came here to train in the 1960s, and I grew up taking it for granted that I'd work in the NHS like her.

    I've been really heartened to see women talking about their experiences with hysteroscopy, as part of the bigger discussion of how we view female pain – forcing our profession, and institutions to recognise that there is a problem. The medical world can be a bit slow to respond to societal changes, but one of the silver-linings of this terrible year, seems to be the acknowledgement that we need to look at our role in perpetuating health inequality. Working in an imperfect system (and being complicit with it) can also take a toll on healthcare professionals, so working with patients to improve their experience, is in our interest too.

    I practiced in New Zealand for a period, where the idea of Cultural Safety was developed by Maori Healthcare workers as a way of addressing disparities in care. I'd love to see some of these ideas adapted for our services, which is why I am currently making it the focus of an MA project .

    What is a hysteroscopy and when would a woman be offered one?

    It's really important that women understand that a hysteroscopy is a pretty invasive procedure – it’s not 'like a smear test'. In the past, they were done under general anaesthetic but development of very fine hysteroscopes means that most cases can now be done in the outpatient setting, with the patient awake. Outpatient Hysteroscopy is now the default option in most units – something that happened, without a lot of consultation, but has considerable benefits.

    The hysteroscope, and pressurised water, are passed through the vagina into the cervix (neck of the uterus/womb) and the uterus itself. Very different to a smear test, which is limited to the vagina and outside of the cervix. Hysteroscopy can be used to investigate possible problems with the lining within the uterus (endometrium), the shape of the uterine cavity, or lesions like polyps or fibroids. As well as being used for investigation, small operations can also be performed using some types of hysteroscopes – for example removing small polyps or fibroids.

    So, you might be offered a hysteroscopy if you have problems like heavy or irregular periods, bleeding after the menopause, a lost contraceptive coil or fertility issues. You may be referred for hysteroscopy if there is a chance that your symptoms may be due to cancer of the endometrium (lining of the uterus/womb), which obviously adds an extra level of anxiety for many women. 

    What pain relief is usually offered to women having a hysteroscopy?  

    For Outpatient Hysteroscopy? Essentially none. Although many women are advised to take paracetamol or ibuprofen an hour prior, there isn't a lot of evidence that it helps, and I question whether it perhaps trivialises the nature of the procedure. As does the recommended distraction technique of 'vocal local', although constant communication and support does seem to help.

    That’s why it's essential that women fully understand that there is a significant risk of severe pain. They can then weigh this up against the fact that Outpatient Hysteroscopy is generally a very quick procedure that avoids the risk and time associated with a general anaesthetic and can be the most efficient way to deal with their problem.

    Some people ask if they can have local anaesthetic. Unfortunately, the nerve supply to the vagina, cervix and uterus, is complex so there isn't a way of making the entire area numb (like when you have dental work). In some women the opening into the cervix can be very tight (stenosed), but generally the pressurised water can overcome this. In a small group of women, the opening may need to be expanded/dilated before inserting the camera, and local anaesthetic injected into the cervix can make this less painful. It’s not that useful for women who do not need to have their cervix dilated – as the injection and speculum themselves can cause pain, but it can be an option.

    Some units do offer nitrous oxide (gas and air), during the procedure, but this is not widespread. Unlike other endoscopic/camera-type procedures you might be familiar with, like colonoscopy (looking in the bowel), Outpatient Hysteroscopy clinics in the NHS don't tend to have been set up with the facility for sedation, although the option is offered at some hospitals. 

    How does this compare with the pain relief offered for other investigative procedures, colonoscopy for example?

    It’s tempting to become a bit defensive at this point but the reality is that hysteroscopy does seem to be trivialised in comparison to other endoscopic procedures. Historically Outpatient Hysteroscopy services haven't been located with other endoscopic services (for example those looking at gastrointestinal tract), with access to sedation and the trained staff, monitoring and recovery this requires. Maybe this is because hysteroscopy tends to be a quicker procedure, but it’s impossible not to speculate that hysteroscopy being a 'woman’s issue' may have been a factor.

    Some clinics run on a 'see and treat' basis, enabling Drs to investigate and treat on the same day, where deemed appropriate. This saves time and resources but what challenges can this 'one-stop' approach present?

    The advantages of one-stop clinics aren't just financial – a lot of women appreciate getting their problem sorted in a single visit. They also help us meet cancer waiting targets and provide quicker diagnosis. However, they do raise questions about truly informed consent. 

    The information provided by a GP on referral, can be variable (especially during the pandemic), and appointments can be very last minute. Leaflets cannot provide personalised information and, in our area, women are often unable to read English. 

    When women arrive, we have to explain that we may, or may not, suggest a scan/examination/hysteroscopy/biopsy/polypectomy etc depending on findings. That’s quite a lot of 'ifs' to understand and consent for, especially just prior to having it done! 

    We are hearing from women who have had severe pain during hysteroscopy. What have patients told you about their pain experiences during hysteroscopy?

    In our audit of the patients in our unit, around 12% said they found the procedure so painful, that they would have preferred to have it under general anaesthetic if asked again – that’s really significant. However, a similar number who had severe pain, were still happy that they opted to have it as an outpatient, and three quarters of women did not rate their pain as severe, so I think it would be a mistake to dismiss all Outpatient Hysteroscopy.

    What causes pain during hysteroscopy?

    I don't really buy this thing about some women 'experiencing pain differently'. I think all women have a physiological reaction to having a hysteroscope and pressurised water inserted into their cervix. Some get severe contraction-type pain, and some don't, but everyone feels it – how could you not?

    Pain is obviously complex, but some of the language used is misleading – like 'discomfort' or 'period-pain'. I have no idea what ‘period-pain’ is meant to feel like! The implication that women who experience severe pain have a 'low pain threshold’, or suggesting that women who have had vaginal deliveries should be fine, isn't helpful either. I don't really think there is really a way of calculating who is at risk of severe pain, more research may be helpful .

    Do you have any tips for colleagues wanting to improve hysteroscopy experiences for women?

    More of us are using a vaginoscopic approach, which definitely helps. But generally, we need to try and make sure women understand all options, and that all decisions are made by them, in collaboration with us. 

    I think it’s important not to downplay the procedure. I introduced the Local Safety Standards for Invasive Procedures (LocSSIPs) checklist in our unit. It’s similar to the one used in theatre and I think this formality orientates and prepares both staff and patients – as well as being an important safety feature. 

    On a practical note, I think it’s useful to explain the shock of cold water to women. I normally tell them I will splash them on the outside of the vulva before we start, so they know what to expect. 

    I also explain the concept of a 'two-step stop' to the woman during the consent. She can ask for the procedure to pause at any time and then I will tell her what part of the procedure we are at/ time left to complete. I then ask her if she would like the entire procedure to stop based on this information. 

    Do you have any advice for women who have been offered a hysteroscopy and may be feeling anxious? 

    It would be unusual not to be anxious but remember that the majority of women find Outpatient Hysteroscopy acceptable and quick. Read any information you are sent and, do your own research too (hearing the experiences of women who have undergone the procedure, on forums like this, is really useful) - you are best placed to make your own decisions. 

    Like with any medical appointment it may be sensible to write down queries to be addressed during your appointment. And clarify beforehand with the operator how you will tell them if you would like the procedure to be stopped, which you can do at any time. Don't assume they will know you are in pain. Generally they can't even see your face. 

    What changes would you like to see for hysteroscopy care? How would these changes need to be driven and by who?

    Without public demand, things don't really change. Those of us working within a system are often surprisingly powerless! In an ideal world, I'd like to see less rush, with adequate time in Outpatient Hysteroscopy, so it felt like less of a conveyor belt and to ensure all consent is well informed. I'm a bit undecided regarding 'one-stop' clinics.

    Hopefully the more widespread use of advanced equipment (like tissue removal systems), will make procedures like biopsies and polyp removal quicker, and more tolerable, but again these are not available in all units. It would be good if the full range of pain relief options, was to be available to women at all units – it’s again too variable. 

    Mostly, I think there has to be a slight shift in culture regarding how we talk about women's experience in our speciality, something I think is thankfully beginning to happen.

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    Having had a painful out patient hysteroscopy some years ago it is refreshing to read this article. It one of the first I have felt that I was not at fault for feeling such severe pain! Thankyou.

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    Dr Sundar - I can't thank you and PSL enough!! 

    You should get a medal for this. 

    You told the truth about outpatient hysteroscopy - and you didn't pretend that "only 3 to 5%" women experience severe pain.

    The Campaign Against Painful Hysteroscopy has been inundated by horrific stories of women crying, screaming, fainting or vomiting during OPH and then feeling that it was somehow their fault.

    I so hope that the BSGE and RCOG include your truthful evidence in their new hysteroscopy guidelines and patient information. 

    Since Montgomery and Cumberlege there is no legal excuse for women not to be warned of the unpredictable risk of severe pain of 7,8,9/10. 

    Women should be given the choice of attempting hysteroscopy in outpatient +/- local anaesthetic/ Entonox should they wish, but equally be given the option of timely GA/ spinal anaesthesia/ IV conscious sedation with analgesia.

    Thank you for caring and speaking up about the basic human right of not being made to endure agonising and degrading medical treatment when safe alternatives exist.

    Katharine

     

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    This is great to see and I particularly like your rebuttal of the claim that individuals 'feel pain differently'. It's all a distraction from the central issue, which is that the pain management aspect of this and related procedures simply hasn't been prioritised. We can speculate on why this might be.

    The option of GA should always be offered up-front while the alternatives are as unacceptable as what you describe here, which is in keeping with what I've heard from women I've spoken to. I do think your point that the location of where gynae procedures are done is also a significant one, and one I hadn't considered before now.

    Could a possible solution be simply to move gynae endoscopy into the same physical locations as all other forms of endoscopy so the same infrastructure is available in terms of sedation etc? If not, why not?

    I had mine under GA and would do so again unless something like this was an option. 

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    My experience was horrendous.  I was told it can be more painful for menopausal women whilst they were gowning me up. I was told by the booking officer that they don’t use anaesthetic anymore. Totally mislead and then tortured.  Menopausal women with long term cervical closure should only have this procedure under anaesthetic. 

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    Thank you Dr Sundir. 

    I believe culture does have to change about talking about women's issues. It is not acceptable to play down the pain caused by a hysteroscopy, trivializing it to that of discomfort and  period like pain and inferring that if it is bad then you are at fault and have a low pain threshold. Pain is too complex and I am very concerned at the tsunami of phsyco biophysical  babble that is interfering with dealing with the serious issue of pain. I like your comment "everybody feels it". 

    With the obvious pressures of finance within the NHS, I do think we need to put the breaks on and give more time to this procedure so that informed consent is obtained, that a calm caring supportive environment is created. That as you said, across the board the wide range of pain relief should be available to all. Your practice of  using a local safety standards for invasive procedures check list would I think challenge a lot of staff to treat it with more respect if introduced nationally. 

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    Thank you for validating women's experience of painful hysteroscopy.  So many feel gaslit by doctors and nurses telling them it is not painful.  Women are being made to feel weak, or somehow inferior for feeling the pain.  They are put under a LOT of pressure to accept outpatient hysteroscopy with no anaesthesia.

    My personal experience, the last time I had a hysteroscopy, was of having to fight for any sort of anaesthesia. I told them I would be happy with gas & air, but this was not available, it would be GA or nothing.  No other options.  So I opted for GA.  At this point every obstacle was put in my way.  I was told they could not do it for months unless I had it without anaesthesia.  Then they tried objecting on medical grounds, but I was able to get other consultants to approve it - which they did.  

    I have many painful autoimmune illnesses and the last thing I need is more pain, but I was made to feel like a silly old woman making a fuss about nothing.  

    This is a growing issue in the NHS, the denial of anaesthesia and the idea that you should be grateful for any sort of service at all - even painful.  I had this when I went for endoscopy, and I chose sedation.  The consultant doing the procedure sneered and made remarks as to why I should need sedation. 

    What will happen in the wake of COVID when many more people are going to be left with chronic problems, I wonder?  People with long COVID are already being told it is in their minds.

    I foresee patients really having to grapple with the system to get any standard of care, and the continuing glorification of fundraisers is inflating the idea that the NHS is a charity - not something for which we have paid.

     

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