Over the past few years, Patient Safety Learning has heard from many patients about significant safety concerns relating to hysteroscopy procedures in the NHS. From the countless women who have shared individual experiences on the hub to the conversations we have had with the patient group the Campaign Against Painful Hysteroscopy, it is clear that this is a topic needing further exploration and advocacy from a patient safety perspective.
I therefore welcomed a recent opportunity to engage with healthcare professionals involved in hysteroscopy procedures and share these concerns when I was invited to attend the Association of Anaesthetists Winter Scientific Meeting 2023 last month. This is the Association’s flagship conference, attended by healthcare professionals from across the UK, and I was invited to contribute to a panel session. This was focused on differing approaches to sedation for hysteroscopy procedures in both operating theatres and outpatient settings.
Healthcare professional perspective from Leeds
Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common problems such as abnormal bleeding, unexplained pain or unusually heavy periods in women. It involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia.
The panel session started with a presentation about hysteroscopies from Dr John Dalton, Dr Tracy Jackson and Maria Chalmers, Specialist Nurse Hysteroscopist. Maria spoke about the approach to hysteroscopy at the Leeds Centre for Women’s Health, emphasising the importance of:
appropriate patient consent for the procedure
discussing the likelihood of pain in advance of obtaining consent
the patient’s right to withdraw consent or stop the procedure at any time.
They described how patients, if they wanted to, were invited to review the procedure on a screen, and reported that there had been positive feedback from patients who have undergone procedures with this option.
They also spoke about the value of these procedures taking place in outpatient settings where possible, creating a quicker diagnostic assessment.
In their presentation, they reflected on the importance of collecting data about patient outcomes and pointed to broadly positive satisfaction scores with their service.
Reflections on consent
It was positive to hear a strong emphasis on the importance of patient consent, both before and during a procedure. It is an area of concern that has been consistently raised with us by patients who have undergone hysteroscopy.
Through our work, we know that a significant number of women are not given sufficient information beforehand about the nature of the procedure or the potential for high levels of pain. Many have told us they were not asked about their medical history or offered different options for pain relief. These patients often reflect that the consent they gave was therefore not informed.
When a patient experiences unexpected levels of pain, they can understandably feel very unsafe. This can lead to lasting trauma and a fear of accessing further important procedures or screenings. It’s therefore essential to make sure women undergoing this procedure feel they have been given all the information available.
I introduced the concerns being expressed by many women and this generated an open discussion with colleagues from Leeds and an engaged audience of anaesthetists, many of whom were unaware of the issues that patients are raising about outpatient hysteroscopy.
In the panel discussion I spoke about the experiences that have been shared with us at Patient Safety Learning. Some women have described how the lack of forewarning about this procedure, coupled with the trauma of the experience itself, left them feeling that both their body and their trust had been violated. Many women have also described receiving little or no pain relief and not being given the information they needed to make an informed choice about their own care and their own bodies.
More than 50,000 people have viewed our community discussion on the hub about hysteroscopy experiences, with many having shared awful experiences exhibiting bullying, lack of compassion, lack of information and horrendous pain. Recent research, published in the British Journal of Anaesthesia, shows that a significant number (17.6%) of women rate their pain during hysteroscopy as greater than 7/10, and only 7.8% report no pain at all.
We know that outpatient hysteroscopy is a valuable procedure when done right, with full information, appropriate pain relief options and informed consent. However, as we have heard all too often from patients, in many cases this is not what they are experiencing. Similar concerns were raised this week in a debate in the House of Commons. When discussing the implementation of good practice in these procedures, Government Minister Maria Caulfield note that such guidance was only as effective as its implementation:
“The royal college is important because it can bring clinical change on the ground, but it is not enough just to assume that its updated guidance will be enough to change what happens in practice.”
Patients and campaigners are not unsupportive of hysteroscopy as a procedure. However, I shared our view, and that of many, that patients should not be expected to tolerate extreme pain or inconsistency of service.
I emphasised a need for:
increased efforts to ensure that good practice is shared widely and consistently applied.
more research to better inform risk assessments about which women are most likely to affected by severe pain.
ensuring that all those healthcare professionals involved in these procedures understand the importance of listening to and responding patients, giving women a range of pain relief options and providing the option to stop the procedure.
It was useful to discuss with Maria and other clinical colleagues the value of hysteroscopy and the efforts that some centres are making to ensure that patients’ needs are met, and their voices heeded.
It was helpful also to see in person the responses of anaesthetists in the room. There was, in some cases, clear concern about the negative experiences that have been shared with Patient Safety Learning by patients.
Then we had some interesting reflections on the pain scores presented by the staff at Leeds. Many anaesthetists expressed shock that despite the good service being provided there, median pain scores are 5 out of 10. Some anaesthetists commented that patients wouldn’t be let out of recovery rooms by nursing staff with that extent of pain, and some said that they themselves wouldn’t want to undergo such a procedure in an outpatient setting with that median pain rating.
The discussion was an important multi-disciplinary conversation of the value of hysteroscopy as a procedure while highlighting the very real concerns that women are experiencing when Royal College of Obstetricians and Gynaecologists guidelines are not being met consistently.
The opportunity to engage in discussion with clinicians who are aiming to put patients’ experience at the heart of their service was much appreciated and we’re going to follow up with Maria and John to hear more about their service and the plans they have for continual improvement and for the best experience for women.
We applaud the Association of Anaesthetists for highlighting these issues and aim to engage further to increase awareness of hysteroscopy pain and the need for urgent action. We look forward to sharing the recording of the session via the hub as soon as it becomes available.
Join the conversation
There is much work still needed to raise awareness of the patient safety issues concerning hysteroscopy procedures and to make the changes required to ensure good practice is applied consistently across the country. In the coming weeks, we will be publishing a new policy blog looking at this in greater detail and considering what more needs to be done to improve patient safety.
In the meantime, if you have an experience you would like to share with us, please do get in touch. Perhaps you are a healthcare professional with insights to share on this topic? A patient who has had a hysteroscopy? A researcher? We'd love to hear from you if have a different perspective to add.
You can join the conversation on the hub or get in touch with us directly by emailing firstname.lastname@example.org.
1. Campaign Against Painful Hysteroscopy, Open letter to the Department of Health and Social Care, 20 October 2020
2. Richard Harrison, William Kuteesa, Atul Kapila, Mark Little, Wiebke Gandhi, Deepak Ravindran, Carien M. van Reekum and Tim. V Salomons, Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy, 13 September 2020
3. Patient Safety Learning, Guidance for outpatient hysteroscopy: Consultation Response, 16 March 2022
4. House of Commons Debate, NHS hysteroscopy treatment, 31 January 2023