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Gynaecology Leaflets

Each of the General Gynaecology leaflets (LWH) are available below, select the heading of the one you would like to view and the content will expand with an option for you to download the PDF version.

Leaflets can be made available in difference formats on request, to view in a different language select the language change in the bottom left of the screen.

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If you would like to make any suggestions or comments about the content of this leaflet, then please contact the Patient Experience Team on 0151 702 4353 or by email at Pals@lwh.nhs.uk.

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  • Support and Guidance Following Your Loss

    The leaflet is detailed below, or you can download the 'Support and Guidance Following Your Loss' leaflet in PDF.

    We wish to offer you our sincere condolences at this sad time.

    We understand that the death of a loved one or friend can be devastating and may cause strong and sometimes confusing emotions.

    We hope that you will find this booklet helpful for all the practical arrangements that need to be made and provide you with information on who can help and offer support through this difficult time.

    What to Do First?

    When Can I See My Loved One Or Friend?

    • When a death has occurred on the ward, you will be given the opportunity to stay with your loved one within the Mulberry or Orchid Suite on the ward before they are transferred to either the chapel of rest at your chosen funeral directors or the facilities at The Royal Liverpool University Hospital, as these facilities are not available at The Liverpool Women’s Hospital.
    • Should you or a member of the family or close friend wish to see your loved one or friend you can arrange an appointment at:

    Royal Liverpool University Hospital,

    Bereavement office

    9:00am - 12:00pm and 1:00pm - 3:30pm, Monday to Friday.

    Please contact 0151-706-3805

    Outside normal working hours please telephone the hospital switchboard on:  0151 706 2000 and ask to speak to the Duty Manager

    Memories

    Many people find themselves thinking about the future and grieving about a time when they or their loved one may no longer be there. This can be particularly difficult if there are children in the family. It’s often upsetting to think that as time goes by, they could forget how much you loved and cared for them.

    The suggestions here can be adapted and facilitated at the hospital to help you create a memory for any loved one:

    • Memory boxes
    • Jewellery boxes
    • Hand/foot moulds
    • Memory book- hospital book of condolences
    • Comfort packs
    • Prayer tree next to the multi-faith prayer room

    Registering the Death

    When somebody dies, you normally need to register their death within five working days. The death has to be registered at a register office.

    It can be quicker to go to the register office in the area where the person you cared for died. If you go to a register office in another area it may take longer to get the documents needed and slow down the funeral arrangements.

    Before a death can be registered, a hospital doctor will need to issue a medical certificate giving the cause of death which must be taken with you to the register office. If the death has been referred to the coroner you will be advised by them when an appointment should be made to register.

    The death can be registered at:

    Liverpool Register Office,

    St Georges Hall (heritage entrance)

    St Georges Place

    Liverpool, L1 1JJ

    Telephone: 0151-233-3004 to make an appointment or book online at www.liverpool.gov.uk

    Or alternatively at:

    Liverpool Women’s Hospital,

    Ground Floor

    Honeysuckle Office

    Telephone: 0151-702-4151

    Appointments can be arranged Mon – Fri

    Who Can Register The Death?

    In most cases a death is registered by a relative. If the person you cared for doesn't have any family who can register their death, the registrar will allow other people to do this. As long as the person died at home or in a nursing home or hospital, their death can be registered by a relative, someone who was present when they died, someone who lived in the same house, an official from the hospital, or the person who is arranging the funeral with the funeral directors

    What Documents Do I Need To Register A Death?

    • The medical certificate, showing the cause of death and signed by a doctor
    • The following are not essential, but if you can find them, you should also take the person’s:
    • Birth certificate
    • Marriage or civil partnership certificate
    • Their NHS medical card

    What Other Information Will The Registrar Need?

    • The registrar will require the following information from you:
    • The date and place of death
    • The full name and surname (and maiden name if the deceased was a woman who married)
    • The date and place of birth (town and county if born in the UK and country if born abroad)
    • The occupation (if the deceased was a married women or a widow, the name and occupation of their husband)
    • The usual address details of any state pension or other state benefit they were receiving

     

    Death Certificates

    • Once the death has been registered, the registrar will give you two important documents.
    • One is a Certificate for Burial and Cremation (green form). This gives permission for the person’s body to be buried or for an application for cremation to be made. Give this to the funeral director.
    • Two, is a Certificate of Registration of Death (form BD8). This is for use in social security matters; for instance, dealing with the deceased person's state pension or other benefits and claims.
    • You can buy extra copies of the death certificate when you register a death. You will need these if you are dealing with the persons affairs or to give to the executor or administrator who is dealing with affairs such as the persons will. The registrar will give you a booklet called ‘what to do after a death’ from the Department of Work & Pensions, that contains advice on several subjects, including paying for the funeral, probate and property, and other practical advice including what to do if the person you cared for died abroad, or in Scotland or Northern Ireland. For more information see UK: what to do after someone dies.

    Coroners and Post Mortem Examination

    Coroner

    In certain situations a death may have to be reported to the Coroner. You will be advised if this has to happen. This generally occurs when a doctor is unable to issue a medical certificate of cause of death due to any of the following:

    • No precise cause can be established
    • The deceased has had an operation within previous 12 months
    • Unnatural causes
    • An injury or a fall
    • Due to an accident or allegations of negligence
    • The death occurs within 24 hours of admission to hospital
    • The death occurs within 30 days of radiotherapy or chemotherapy treatment
    • The death occurs in custody

    Coroner’s Post Mortem

    The Coroner may order a post mortem examination to determine the exact cause of death, if the Coroner orders a post mortem examination, then it becomes a legal obligation; therefore permission from relatives or next of kin is not required.

    Once the results of the examination are known, if an inquest is not required, a certificate to register the cause of death will be issued by the Coroner’s Office.

    Hospital Post Mortem

    Hospital post mortems are not needed by law but are requested by doctors or the next-of-kin when they need more information regarding the death. This can help families and doctors understand the cause of death and may help others with a similar illness in the future. The doctors have to ask your permission to perform a hospital post mortem and you will be asked to sign a consent form.

    The Funeral Director

    Your chosen funeral director will advise you on all matters concerning the funeral and will help you to make decisions regarding anything which you are unsure of.

    Funeral arrangements can be made at any time, although the date when a funeral can be held may be affected if the Coroner is involved.

    The chosen funeral director will need the registration form (green form) which is issued by the registrar, to arrange either burial or cremation.

    Advice on Finance 

    If you receive income support, family credit and/or housing benefit, you may be entitled to help with funeral costs. To apply or ask for information, contact your local Department for Work and Pensions, 0845 606 0265 http://www.dwp.gov.uk/docs/dwp1027.pdf

    Where relatives are seeking help with the financial costs of the funeral they should first contact the Department for Work and Pensions for confirmation before registering the death.

    Who to Inform?

    When someone dies, informing the official organisations such as local government agencies and departments can be a repetitive and difficult process.

    ‘Tell us once’ is a service that lets you report a death to most government organisations in one go unfortunately this service is not available in the Liverpool area.

    However, please ask at your local register office if this service is available.

    Please use the following as guidance to who to inform:

    • GP                                                    
    • Electric/gas
    • Any hospital
    • Council Tax
    • Inland Revenue
    • Social services (home care)
    • Department of Working pensions
    • Passport office
    • Place of work            
    • DVLA
    • Solicitor
    • Royal Mail
    • Bank
    • Housing (landlord)
    • Insurance company
    • Library
    • Motor insurance
    • Careline

     

    Bereavement Support

    • Members of the Hospital Chaplaincy Team visit the hospital on a regular basis, offering aspects of pastoral care as required. Should you wish to meet one of the team, contact can be made via the hospital switchboard 24 hours 7 days per week.
    • There is also open access to our multi faith room located on the ground floor near the main reception
    • If known to the Macmillan team, they will send you a bereavement card after the death of your loved one and a bereavement survey three months after the death of your loved one.
    • The Hospital Macmillan Team are also available for ongoing bereavement support and can be contacted via the hospital switchboard Mon-Fri 08.30-4.30 or 0151-702-4186 (answerphone)

    Useful Organisations

    Age UK

    National advice line: 0800 055 6112

    www.ageuk.org.uk/helpline

    Alder centre at Alder hey Hospital (following death of a child)

    01512525391

    9am-5pm Mon to Thurs and 9-4.30 Fri

    www.alderhey.nhs.uk

    Bereavement support (NHS choices)

    www.nhs.uklivewell/bereavement/pages/bereavement

    Carers UK

    Helpline: 08088087777

    www.carers.uk.org

    Gingerbread (single parent helpline)

    Tel: 01616367540

    www.gingerbread.org.uk

    Compassionate friends (support for bereaved parents and their families)

    Helpline: 03451232304

    www.tcf.org.uk

    Cruse bereavement care (for children, young person and adult support)

    National helpline: 08088081677

    www.cruse.org.uk

    Department for Work and Pensions

    Tel: 0845 6060 265

    www.dwp.gov.uk

    Samaritans

    National Helpline: 08457 90 90 90

    www.samaritans.org.uk

    Macmillan cancer support

    National helpline: 0808 808 00 00

    Mon-fri 09.00-20.00

    www.macmillan.org.uk

    Marie curie-(bereavement service)

    08000902309

    www.mariecurie.org.uk 

    Organ donation

    National helpline: 0300 123 23 23

    www.organdonation.co.uk

    Winston’s Wish (supporting bereaved children and young people)

    National Helpline: 08088 020 021

  • The Menopause - Short Term & Long Term Effects

    The leaflet is detailed below, or you can download the 'The Menopause - Short Term & Long Term Effects' leaflet in PDF.

    The Menopause

    The menopause is the stage in a woman’s life when her ovaries stop producing eggs. This leads to a gradual decrease in levels of hormones oestrogen and progesterone, which in turn leads to the gradual disappearance of monthly periods. The fall in hormone levels can trigger a range of symptoms, although each woman’s experience can be different. The process of the menopause can take several years. A woman is said to be postmenopausal when she has had no period for one year.

    The average age at which women in the UK start the menopause is 51, and for most women it happens between the ages of 45 and 55.

    To prevent pregnancy, it is recommended that contraception is continued for one year after the last period if this occurs after 50 years of age, and two years if periods end before 50 years of age.

    Premature Menopause

    Although most women will reach their menopause in their late forties or early fifties, for a minority of women it can happen earlier. Premature menopause occurs before the age of 40. Some women experience menopause in their thirties or even their twenties, although this is uncommon.

    Surgically Induced Menopause

    A woman becomes menopausal if she has a hysterectomy and at the same time both her ovaries are removed.

    When this happens, the natural process of gradual decline in hormone levels does not happen. Instead, the absence of the ovaries means that hormone levels fall at once and the woman can experience symptoms of menopause more suddenly than if she were to have a natural menopause.

    Occasionally, the blood supply to the ovaries can be interrupted during an operation; and this can lead to menopause occurring soon after surgery – even if the ovaries have not been removed.

    How the Menopause Might Affect You

    Menopause is a natural event that all women will experience. Many women have no problems. Below are the most common menopausal signs and symptoms. They are caused by falling oestrogen levels:

    Menopause - Short-Term Effects

    Irregular Periods

    The most common early sign is irregular or fluctuating periods. This can involve longer than normal cycles and missed periods.

    Hot Flushes/Night Sweats

    Three out of four women have hot flushes and night sweats during their menopause. They usually start as a feeling of pressure in the head, followed by a wave of heat passing over the body. 

    Vaginal Dryness

    Most women experience vaginal dryness during the menopause. This is because the vaginal tissue becomes thinner as a result of lower oestrogen levels. (See Atrophic Vaginitis leaflet).

    Aches and Pains

    Joints may start to feel stiffer, painful or weak.

    Skin and Hair Changes

    Skin can become dryer and hair brittle.

    Sleep Disturbance

    Altered sleep patterns can be a problem.

    Mood, Confidence and Concentration Changes

    Lack of concentration and clear thinking can affect some women. Psychological changes, including irritability, tearfulness and mild depression are also common. It is understandable to feel a wide range of emotions during this time of major change.

    Loss of Sex Drive

    A loss of interest in sex can be caused by some of the emotional and physical symptoms of the menopause.

    Stress Incontinence

    Lack of oestrogen causes the lining of the bladder to become thinner, which may make it harder to control the passing of urine. Passing urine more often or noticing small ‘leaks’ when coughing or sneezing are also common.  Urine infections can also occur.

    Menopause – Long-Term Effects

    Even though the short-term symptoms appear more unpleasant, it is the long-term symptoms of oestrogen deficiency that can cause the more serious health problems.

    When a woman reaches the menopause, her risk of developing Heart Disease and Osteoporosis increases as a direct result of the decrease in oestrogen:

    Heart Disease

    Cardiovascular disease is the most common cause of death in western women. Before the menopause, fewer women suffer from the condition than men, but, from the menopause onwards, incidence increases.

    The role of oestrogen in protecting the heart and blood vessels is very important; the body’s own oestrogen prior to the menopause is understood to have a positive effect on cholesterol levels and general body fat distribution.

    Osteoporosis

    Osteoporosis is a condition of the bones, where a gradual thinning of the bone causes them to become brittle and fragile, leading to a stooping posture, backache and an increased risk of fractures. Lack of oestrogen is partly responsible for Osteoporosis. 

    Managing Symptoms of the Menopause

    There are many approaches to managing menopause symptoms – see accompanying leaflets on HRT and alternative approaches to symptom management:

    • Avoid caffeine and reduce alcohol to improve sleeping and flushes.
    • Wear loose layers of clothing and consider swapping duvet for blankets to help cope with flushes, sweats and chills.
    • Cut down or ideally stop smoking.
    • Eat a balanced diet, rich in Calcium, Magnesium and Vitamin D to protect bones, and Omega 3 for heart health.
    • Keeping weight in health BMI range will reduce menopause flushes and protect against many cancers - in particular breast cancer.
    • Regular exercise will improve mood. Weight bearing exercise helps keep bones strong.
    • Relaxation/mindlessness/meditation will reduce menopause symptoms and improve general wellbeing.
    • Cognitive Behaviour Therapy (CBT) can relieve low mood, anxiety and flushes.

    References:

    British Menopause Society                             (www.thebms.org.uk)

    Clinical Knowledge Summaries                      www.cks/patient information

    Menopause Matters                                        www.menopausematters.co.uk

    National Institute for Health and Care

    Excellence (NICE) 2015

    Menopause: Diagnosis and

    Management                                                   www.nice.org.uk/guidance/ng23

    Royal College of Obstetricians and

    Gynaecologists (RCOG) Menopause

    Patient Information Hub                                  www.rcog.org.uk/en/patient

  • Hormone Replacement Therapy (HRT)

    The leaflet is detailed below, or you can download the 'Hormone Replacement Therapy (HRT)' leaflet in PDF.

    HRT is a prescription only treatment that replaces some of the lost oestrogen and progesterone hormones which occur during menopause. It can be used to relieve symptoms of menopause. If an early menopause has occurred, it is often recommended that a woman takes HRT until she reaches the usual menopause age – to maintain bone and heart health.

    In recent years there have been concerns raised about HRT and the potential risks to various aspects of women’s health.

    This leaflet sets out the known facts about HRT. It briefly summarises the results of studies regarding its safety and addresses the controversy that still surrounds its’ use.

    In the 1990’s two of the largest studies on HRT were undertaken; a clinical randomised trial in the USA Women’s Health Initiative (WHI), and an observational questionnaire in the UK –Million Women Study (MWS). The initial results of these two studies were published during 2002 and 2003 and raised concerns regarding the safety of HRT. In particular, results suggested that prolonged use of HRT increases the risk of breast cancer, and that HRT can increase the risk of heart disease.

    The findings received wide publicity and caused panic amongst users and healthcare professionals.

    As a result many women chose to, or were advised to stop taking their HRT.

    A number of expert panels, including The British Menopause Society, responded by identifying flaws and shortcomings with both studies:

    The women in the WHI study were North American. Many were obese and in their mid-sixties. Their risk of cancer, stroke and heart disease would therefore be higher than in younger, none obese women. WHI only looked at one dose and type of HRT. The dose used was considered too high (by UK Experts) for these older women, and would generally not be used in the UK. Therefore the results are not comparable to common practice in the UK.

    MWS’s research methodology has been criticised. The women were self-selecting and self-reporting HRT users, many dropped out of the study, and since it was not a randomised controlled trial, there wasn’t a control group to compare findings against. Follow up was undertaken through cancer registries, not by further questionnaires – so changes in HRT usage after initial registration were not recorded.

    When the full WHI results were subsequently published it showed that the apparent increased risk of breast cancer was only found in women who were already taking HRT before entering the study.

    The authors of WHI now state that the risk of breast cancer was exaggerated: Increase in risk of breast cancer with combined HRT in WHI was much less than initially reported and equates to 4 extra cases per 1000 women after 5years use (this risk is less than that caused by smoking 10 cigarettes/day, alcohol and obesity). Other risks were exaggerated whilst benefits for middle-aged women were disregarded.

    In addition, whereas the reports initially claimed that there was no difference in risks with age, further analysis of the WHI report confirms that starting HRT after the age of 60 may increase the risk of heart disease. Both studies showed no increase in heart disease in women starting HRT within 10 years of the menopause.

    Follow up studies carried out by some of WHI’s leading investigators now say that the benefits of HRT outweighs the risk for healthy women in their 50s who are suffering from menopause symptoms. Probert Langer, Principal Investigator of WHI says “with 10 years hindsight we can put the lessons learned from the WHI trial into perspective. Overgeneralising the results from the women who were, on average, 12 yeas post menopause to all (younger) post menopause women has led to needless suffering and lost opportunities for many. A further report from Dr Langer, published 2017, concludes that "it is time to get past the misinformation and hysteria generated by the highly irregular circumstances of the WHI and stop denying potential benefits (control of vasomotor symptoms, prevention of fractures and coronary heart disease) to women."

    This about turn and retraction of some of the previous findings has received little publicity in the media.

    Level of risk for HRT use has actually remained unchanged for many years.

    In 2015, NICE published the first national Menopause guidance. A review of risks and benefits of UK prescribed HRT was undertaken. Their findings are in line with the full published results of both WHI and MWS. Findings are summarised below.

    In conclusion, for the majority of women, HRT is a safe and appropriate option – in conjunction with improving lifestyle. It is generally recommended that the lowest dose of hormone to relieve symptoms is prescribed. Although it is an individual decision when to stop HRT, risks will increase with age – particularly after 60 years of age.

    It is recommended that all women using HRT have a yearly check-up with their GP.

    Simple lifestyle changes (for example -reducing alcohol and caffeine, reducing/stopping smoking, losing excess weight and increasing exercise) will also definitely improve menopause symptoms, and reduce risk of age-related diseases.

    Non hormonal alternatives to HRT are available – see relevant leaflets.

    Benefits of HRT

    The most noticeable effects of taking HRT are a reduction in menopausal symptoms, which can often respond quite rapidly to treatment.

    Perhaps even more importantly, HRT provides significant protection against osteoporosis; however, HRT is only licensed for second-line use in the prevention of osteoporosis. Although itis recognised that HRT offers some protection against cardiovascular disease and dementia, it is also not licensed for these purposes.

    There are many different types of HRT preparations and doses available, so it is possible that not every woman will find that the first HRT she tries is the one that suits her best. It is recommended that at least 3 months commitment to a dose and preparation of HRT is necessary to fully assess its effectiveness.

    The Different Forms of HRT

    Tablets, Patches, Gels & Implants

    HRT is most commonly prescribed in tablet form and there are many different brands available containing varying combinations of oestrogen alone or in combination with progestogen. HRT can also be prescribed in patch or gel form. This is particularly useful for women with bowel dysfunction (IBS, Crohns, Diverticulitis etc.), or a history of clotting problems. Occasionally hormones can be delivered via implant that lasts approximately 6 months at a time. Unfortunately, implants are currently not being manufactured in the UK.

    Local HRT

    This includes creams, tablets, pessaries and rings which are inserted into the vagina, where the oestrogen helps reduce vaginal dryness (see atrophic vaginitis leaflet).

    Main Classes of HRT

    There are three major types of HRT, and the one a woman receives will depend on whether she has just begun her menopause is postmenopausal, or whether she has had a natural or surgical menopause

    1. Oestrogen Only HRT:

    This is recommended for women who have had their womb removed by a hysterectomy. Because the role of progesterone is to protect the womb lining (endometrium), this group of women generally do not need progesterone and are therefore usually prescribed oestrogen only HRT (see hysterectomy and menopause leaflet).

    2.Cyclical or Sequential HRT:

    This HRT is recommended for women who have had a natural menopause, or who are approaching the menopause but are still having periods (perimenopause). Cyclical HRT contains oestrogen and a progestogen (a form of progesterone) and this will produce regular bleeding to protect the endometrium.

    3.Continuous Combined or Period-Free HRT:

    This is recommended for women who have not had a period for at least one year and are therefore post-menopausal. Period-free HRT contains similar hormones to cyclical HRT but, does not stimulate period bleeding. Period-free HRT can be started straight away if you have not previously been on any HRT and are post- menopausal. Swapping from cyclical HRT to period-free HRT is recommended after 5 years of cyclical HRT usage, or at age 54.

    Contraception

    HRT does not generally have a contraceptive effect (exceptions include mirena IUS and Qliara contraceptive pill).Therefore you should continue to use an alternative, non-hormonal form of contraception -for one year after last period if over50 years of age, and two years if less than 50.

    Side Effects to HRT

    Side-effects with HRT are uncommon. In the first few weeks some women may develop slight nausea, some breast discomfort or leg cramps. These tend to settle within a few weeks. Some women report more headaches or migraines whilst taking HRT. Skin irritation can occur with HRT patches.

    Contraindications to Taking HRT

    HRT may not be recommended for some women with –

    • A history of gynaecological cancers.
    • A history of blood clots (DVT, PE, stroke)
    • A history of heart attack
    • Uncontrolled hypertension
    • Severe liver disease
    • Pregnancy
    • Undiagnosed vaginal bleeding
    • Undiagnosed breast lump

    Risks Associated With Taking HRT

    Generally, for healthy, younger women, within 10 years of their menopause, the benefits of HRT outweigh the risk. However, older women, over 60 years of age and beyond, are often at higher risk of cardiovascular disease, and therefore, the risk of HRT often outweighs the benefits. See tables overleaf.

    Table 1 Absolute rates of coronary heart disease for different types of HRT compared with no HRT (or placebo), different durations of HRT use and time since stopping HRT for menopausal women:

     

     

    Difference in coronary heart disease incidence per 1000 menopausal women over 7.5 years (95% confidence interval) (baseline population risk in the UK over 7.5 years: 26.3 per 10001)

     

     

    Current HRT

    users

    Treatment duration

    <5 years

    Treatment duration

    5–10 years

    >5 years since stopping

    treatment

    Women on

    oestrogen

    alone

    RCT estimate2

    6 fewer

    (-10 to 1)

    No available

    data

    No available

    data

    6 fewer (-9 to -2)

    Observational

    Estimate 2

    6 fewer

    (-9 to -3)

    No available

    data

    No available

    data

    No available

    data

    Women on

    oestrogen &

    progestogen

    RCT estimate 2

    5 more

    (-3 to 18)

    No available

    data

    No available

    data

    4 more (-1 to 11)

    Observational

    Estimate 2

    No available

    data

    No available

    data

    No available

    data

    No available

    data

    HRT, hormone replacement therapy; RCT, randomised controlled trial

    For full source references, see Appendix M in the full guideline.

    1 Results from Weiner 2008 were used for the baseline population risk estimation.

    2 For women aged 50–59 years at entry to the RCT.

    3 Observational estimates are based on cohort studies with several thousand women

    Table 2 Absolute rates of stroke for different types of HRT compared with no HRT (or placebo), different durations of HRT use and time since stopping HRT for menopausal women:

     

     

    Difference in coronary heart disease incidence per 1000 menopausal women over 7.5 years (95% confidence interval) (baseline population risk in the UK over 7.5 years: 26.3 per 10001)

     

     

    Current HRT

    users

    Treatment duration

    <5 years

    Treatment duration

    5–10 years

    >5 years since stopping

    treatment

    Women on

    oestrogen

    alone

    RCT estimate2

    0

    (-5 to 10)

    No available

    data

    No available

    data

    1 more (-4 to 9)

    Observational

    Estimate 2

    3 more

    (-1 to -8)

    No available

    data

    No available

    data

    No available

    data

    Women on

    oestrogen &

    progestogen

    RCT estimate 2

    6 more

    (-2 to 21)

    No available

    data

    No available

    data

    4 more (-1 to 13)

    Observational

    Estimate 2

    6 more

    (-2 to 21)

    No available

    data

    No available

    data

    No available

    data

    HRT, hormone replacement therapy; RCT, randomised controlled trial

    For full source references, see Appendix M in the full guideline.

    1 Results from Weiner 2008 were used for the baseline population risk estimation.

    2 For women aged 50–59 years at entry to the RCT.

    3 Observational estimates are based on cohort studies with several thousand women

    References:

    British Menopause Society                                                     www.thebms.org.uk

    Clinical Knowledge Summaries                                              www.cks/patient information

    Menopause Matters                                                                www.menopausematters.co.uk

    National Institute for Health and Care                                    www.nice.org.uk/guidance/ng23

    Excellence (NICE) 2015 Menopause:

    Diagnosis and Management                                                  

    NHS patient information                                                         www.patient.co.uk/menopause

     

    Royal College of Obstetricians and                                        www.rcog.org.uk/en/patients

    Gynaecologists (RCOG) Menopause

    Patient Information Hub

  • Having a Trans-Vaginal (Internal) Scan

    The leaflet is detailed below, or you can download the 'Having a Trans-Vaginal (Internal) Scan' leaflet in PDF.

    Introduction

    You have been referred for a transvaginal (internal scan) to help assess the health of your pregnancy. This leaflet has been designed to explain what this involves. It may not answer all of your questions, so if you have any queries, please ask the staff who will be performing the scan, who will be happy to help and advise you.

    What Is An Ultrasound Examination?

    An ultrasound picture is formed by sound waves, which are passed through the body and reflected back as an image. This can be performed trans-abdominally (through the tummy and with a full bladder), but below 12 weeks is usually performed trans-vaginally (internally) as this provides clearer pictures of the womb, ovaries and surrounding structures.

    Why Have I Been Booked For A Trans-Vaginal Scan?

    The aim of the scan is to assess the health of your pregnancy. You may have experienced bleeding, potting or pain or require a reassurance scan due to a history of recurrent miscarriage or ectopic pregnancy. It is a safe and generally painless procedure. There is no evidence that having a trans-vaginal scan can cause miscarriage or harm a pregnancy. Sometimes there might be a concern that the pregnancy is in the wrong place, what is called an ectopic pregnancy. In this situation, we would advise a trans-vaginal scan, as ectopic pregnancies may not be visible on a trans-abdominal scan.

    What Will Happen During The Scan?

    You will need to empty your bladder just before the scan and undress from the waist down. A specially designed ultrasound probe is used, that is covered with a protective sheath and lubricating gel. This is gently inserted into the vagina and is then moved into different positions in order to see the womb and ovaries clearly.

    What Happens After The Scan?

    If the scan shows a healthy pregnancy, you will be discharged and advised to continue with routine antenatal care with your doctor or midwife. If the scan shows any abnormalities, such as a possible miscarriage or ectopic pregnancy, then you will be referred to the Gynaecology Emergency Department, where you will be reviewed by one of the doctors or Advanced Nurse Practitioners. They will discuss the findings and management options with you.

    Further information?

    If you require any further information about your scan, please contact Gynaecology Emergency Department on 0151 702 4438

    Change of appointment – Access Centre on 0151 247 4747

    In an emergency, please contact the on 0151 702 4140 for further advice.

  • Polycystic Ovarian Syndrome (PCOS)

    The leaflet is detailed below, or you can download the 'Polycystic Ovarian Syndrome (PCOS)' leaflet in PDF.

    What is PCOS?

    Polycystic ovarian syndrome (PCOS) is a condition where the ovaries contain more developing eggs than is usual. However, most of these eggs never fully mature and are not released from the ovary.

    The ovaries produce the female hormones oestrogen and progesterone, and a small amount of male hormone, testosterone. 

    In PCOS these hormones are often unbalanced. Another hormone, (insulin), which is responsible for keeping blood sugar at a normal level, becomes less effective in PCOS. These imbalances cause the classical symptoms of PCOS:

    • Irregular, infrequent or no periods,
    • Difficulty in getting pregnant,
    • Weight gain, and difficulty in losing weight,
    • Acne,
    • Excessive body hair.

    Not all women have all these symptoms, and each symptom can vary from mild to severe. Around 10 out of every 100 women have PCOS and most have no symptoms.

    The cause of PCOS is genetic, and for this reason, it does tend to run in families.

    Can PCOS be cured?

    No. If you have been diagnosed with PCOS, you will always have it. Although the symptoms can become more obvious if your weight increases.

    What Treatments Are Available?

    Treatment varies from one woman to another. It depends on what, if any, aspect of PCOS the woman has concerns with. For example, there are treatments available to help with infertility, weight loss, excess hair, acne and irregular periods.

    Your GP (General Practitioner) may also be able to offer support and advice about weight loss and healthy living.

    Are There Any Long Term Health Risks?

    Having PCOS can lead to an increased risk of diabetes, due to long term resistance to insulin. Gestational Diabetes (diabetes in pregnancy) is also an increased risk for women with PCOS. Testing for gestational diabetes should be performed between 24-28 weeks of pregnancy, with referral to a specialist obstetric diabetic service arranged if results are abnormal.

    High blood pressure and high cholesterol levels; which can all lead to heart disease are risks of being very overweight and having hormone imbalances.

    Having no or very infrequent periods can cause the lining of the womb to thicken, which can sometimes lead to cancer of the womb.

    What Can Help Reduce The Long Term Health Risks?

    Following a balanced diet, taking regular exercise and maintaining an appropriate weight are the main ways in which you can help yourself to reduce the long term health risks associated with PCOS.

    • If you are overweight, losing weight will help. All the symptoms of PCOS can be greatly improved by weight loss.
    • If you are not overweight, you should take care to keep your weight within the normal range for your height.
    • Women with PCOS are more likely to develop Diabetes. One or two in every ten women with PCOS will go on to develop Diabetes in the future.

    Diabetes occurs when the hormone insulin is unable to regulate the amount of sugar in your blood. This is called “insulin resistance.”                         

    Excess fat causes the body to produce more insulin, so being overweight greatly increases the risk of insulin resistance and diabetes.                        

    • If you have few periods, or no periods at all, the lining of the womb may be more likely to thicken. Having regular periods prevents this happening. If the lining thickens, it can increase the risk of cancer in the womb. To reduce the risk, there is medication available to ensure you have a regular period.

    If you are overweight, or have a family history of heart disease or diabetes, you may be offered regular (yearly) tests on the levels of cholesterol and fats in your blood, and on the levels of sugar in your urine and blood.

    For more information about PCOS, speak to your Doctor or Nurse, or contact the Self Help group below:

    Verity – The polycystic Ovaries Self Help Group

    52-54 Featherstone Street

    London EC1Y 8RT      

    www.verity-pcos.org.uk

    Refs:

    Patient information leaflet PCOS, Royal College of Obstetricians and Gynaecologists 2015. www.rcog.org.uk/en/patient-leaflets

    Royal College of Obstetricians and Gynaecologists,

    Green Top guideline no 33; Long-term consequences of PCOS, 2014

    www.rcog.org.uk

    For further information please contact staff at Gynaecology Outpatient Clinic at Liverpool Women’s NHS Foundation Trust on 0151 708 9988 Ext 4443

  • Pregnancy of Unknown Location (PUL)

    The leaflet is detailed below, or you can download the 'Pregnancy of Unknown Location (PUL)' leaflet in PDF.

    Introduction

    Following an ultrasound scan you have been diagnosed with a condition called ‘pregnancy of unknown location’. During the scan it has been identified that your womb is empty despite a positive urine pregnancy test. PUL can be a confusing diagnosis so we hope this leaflet helps to try and explain what it means and what could happen next.

    A Pregnancy of Unknown Location Could Mean One of the Following Three Possibilities

    • An early intrauterine pregnancy. The pregnancy could be in the right place but is too small to be seen on scan. Pregnancy tests are now very sensitive and can detect pregnancy hormones even just a few days after conception. This can give an unclear picture especially if you are unsure of the date of your last period or have irregular periods.
    • An early miscarriage has occurred or the pregnancy is failing sometimes if you have had vaginal bleeding it is possible that the pregnancy has passed and this is why it is no longer visible on scan.
    • The pregnancy is located somewhere other than the womb. This is called an ‘ectopic pregnancy’ which would need to be investigated further as it is potentially life threatening if not treated in the early stages.

    What Happens Next?

    At the moment we cannot be sure which of the above three possibilities applies to you. To help us find out what is happening with your pregnancy we will need to look at the level of pregnancy hormone (HCG) in your blood and how much this increases / decreases over a 48 hour period. You will be able to go home and arrangements will be made for you to attend for the second blood test.

    • Early intrauterine pregnancy – HCG levels in this case would rise significantly. This would suggest the pregnancy is in the right place but it is too early to be seen on scan. Should this be the case a repeat scan would be arranged in 10 – 14 days’ time.
    • An early miscarriage – HCG levels would drop significantly. Information on miscarriage will be provided and you will be asked to perform a home pregnancy test in 2 – 3 weeks to ensure hormone levels have returned to pre-pregnancy levels.
    • An ectopic pregnancy – the HCG level may increase, but not significantly or stay the same. Even if this happens we still cannot confirm an ectopic pregnancy until further investigations have been made. If you are suspected of having an ectopic pregnancy you will be reviewed by a senior doctor and may have to be admitted to the hospital for observation if you are unwell.

    Further Advice

    For each of the potential outcomes we would ask you to watch out for any of the following symptoms:

    • Bleeding
    • Pain / change in nature of pain
    • Diarrhoea
    • Vomiting
    • Feeling unwell
    • Collapse or fainting episode
    • Shoulder pain.

    Please contact the Gynaecology Emergency Department on 0151 702 4140 if you develop any of the above and you will speak with one of our nurses who can offer advice.

    Alternatively you are welcome to attend the department for assessment at any time. We understand this can be a very confusing and upsetting time, therefore we would like to reassure you that our department is open 24 hours a day 7 days a week where trained staffs are available to help you.

    If you have any questions please do not hesitate to ask.

  • Metformin Tablets 500mg or 850mg

    The leaflet is detailed below, or you can download the 'Metformin Tablets 500mg or 850mg' leaflet in PDF.

    Why Has The Doctor Given Me Metformin?

    Your doctor has prescribed Metformin for Polycystic Ovary Syndrome. Polycystic Ovary Syndrome (PCOS) has many symptoms which include:

    • Menstrual Irregularities
    • Difficulty Conceiving
    • Miscarriage
    • Skin Problems

    The doctor will explain this condition to you and how it has caused your problems. Metformin is being used to relieve symptoms and increase fertility.

    Are These Tablets Used For Any Other Medical Condition And How They Work In PCOS?

    Metformin is mostly used for the treatment of diabetes. It is possible that you have a resistance to insulin which means that you are not using the insulin that you make as well as you should. This is known to aggravate PCOS. Metformin helps with this.

    How And When Do I Take Metformin?

    Your doctor will tell you how many Metformin tablets to take and how often. Take Metformin during or just after meal times with a tumbler full of water.

    What Should I Do If I Forget To Take My Medicine?

    Take your tablets as soon as you remember. If your next dose is nearly due, take a dose now and miss out the next dose completed, then continue as prescribed. If you miss a whole day or more, continue taking your tablets as usual when you remember. Do not take the missed doses.

    How Do I Store My Medicine?

    Keep out of reach of children. Never share your medicines. Return any unused medicines to your local chemist or hospital pharmacy for disposal.

    What about Side Effects?

    Usually Metformin does not cause many side effects. If you do get an upset stomach or diarrhoea, do not stop taking the tablets. This discomfort will probably go away in two weeks. It helps to always take the tablets with food.

    The doctor sometimes suggests starting on a lower dose and building the dose up over time to reduce this side effect.

    Tell Your Doctor Or Pharmacist If You Are Worried Or Think Metformin Is Causing You Any Problems.

    It is safe to drive while taking Metformin. However, if you are taking any other medicines, ask your doctor or pharmacist if this will affect your driving.

    Can I Drink Alcohol?

    Provided only small amounts of alcohol are taken in, there are no special problems. However, ask your doctor or pharmacist if you are unsure.

    Can I Take Other Medicines Too?

    Tell your doctor if you are taking any medicines, whether they are prescribed or bought in the chemist. Tell your pharmacist you are taking Metformin when you buy any medicines over the counter in the chemist or supermarket.

    Pregnancy and Breastfeeding?

    For some women with PCOS they are using Metformin to help they get pregnant. If you think you are pregnant tell your doctor and do not start taking Metformin. If at any time while you are taking Metformin you think you might be pregnant tell your doctor immediately.

    If you want to breast-feed while taking Metformin you should check with the doctor or pharmacist before you feed you baby breast milk.

    References

    Management of PCOS in adults (2018)

  • Endometriosis

    The leaflet is detailed below, or you can download the 'Endometriosis' leaflet in PDF. 

    What is Endometriosis?

    Endometriosis is a condition where tissue similar to the lining of the womb (endometrium) is found outside the womb. About 1 out of 10 women of childbearing age may have endometriosis and symptoms typically present between the ages of 25 and 40.

    Any woman in the reproductive period of her life (teenage years until the menopause) can be affected.

    Endometriosis tissue can be found anywhere in the pelvis, but most commonly it is found on the ligaments that support the uterus (the uterosacral ligaments) or on the ovaries; occasionally it can be found in the bladder or bowel, affecting their function.

    Endometriosis tissue are responsive to hormones produced by the ovary. When the lining of the womb thickens and grows each month and breaks down as a period in response to the ovarian hormones, endometriosis tissue does the same. However, this cause accumulation of blood and inflammatory material near the endometriosis tissue. For instance, altered blood can be collected in an ovary as a cyst called endometrioma or a chocolate cyst.  Endometriosis is not a malignant disease (not cancerous), and disappears after menopause.

    Endometriosis doesn’t always cause symptoms. In those who have symptoms, we believe the inflammation and scarring in the surrounding tissue have a role in causing the symptoms such as pelvic pain. The scarring may appear as filmy webs that are called “adhesions”. These adhesions can cause the pelvic organs to stick together. There are varying degrees of endometriosis; Some women may only have few spots of endometriosis (mild endometriosis) while in others the disease may be widespread throughout the pelvis. In very severe cases the pelvic organs such as womb, bowels and ovaries can become fixed and attached to each other and made immobile by the scar tissue. This we believe can lead to severe pain. However, severity of symptoms do not mean severe disease. So you may have severe pelvic pain, but either no endometriosis or mild disease, where as some women have severe endometriosis with very little symptoms.

    What Causes Endometriosis?

    The exact cause of endometriosis is not known. There are many theories that includes, backflow of tissue shed with menses in to the pelvis through the fallopian tubes (retrograde menstruation); or a genetic cause because in some women it is found in other close relatives (mother, aunts, daughters etc.).

    What are the symptoms?

    Some women who have endometriosis have no symptoms; however common symptoms include:

    • Pain before the period starts
    • Pain during periods (dysmenorrhoea)
    • Pain during intercourse (dyspareunia)
    • Heavy periods (menorrhagia)
    • Infertility – difficulty getting pregnant
    • Uncommon symptoms include pain when bowels have opened, pain in the lower abdomen when passing urine and blood in the urine or faeces. Very rarely, patches of endometriosis can occur in other sites of the body. This can cause unusual pains in various parts of the body that occur at the same time as period pains. 

    How is Endometriosis Diagnosed?

    There are no blood tests used in the clinic to diagnose endometriosis.

    Ultrasound scans and MRI scans can suggest a diagnosis of particular types of endometriosis, such as endometriosis cysts in the ovaries or severe endometriosis involving bowels, but may not always diagnose the common form of mild endometriosis.

    Definite diagnosis of endometriosis can be made by examining the pelvis during surgery (usually laparoscopy or key hole surgery: see separate patient information leaflet: Laparoscopy), when the spots/patches/ ovarian cysts made by endometriosis tissues are seen and can be biopsied and tested in the lab.

    Active areas of endometriosis can be seen as red vesicles (blisters), or blue spots where altered blood collected in these and white or brown patches represent older or inactive endometriosis. Extensive adhesions, lumps of endometriosis tissue (nodules) and endometrioma (endometriosis cysts on the ovaries) can also be seen during a laparoscopy surgery carried out to diagnose the disease.

    How does Endometriosis Progress?

    The natural cause of endometriosis is currently unknown. The available limited evidence from research studies suggest that untreated endometriosis may get better in 3 out of 10 women; becomes worse in 3 out of 10 women; whilst remain unchanged in the remaining women without treatment.

    At present there are no curative treatment for endometriosis or associated symptoms, and when offering treatments to women with endometriosis, doctors cannot predict who are likely to have their endometriosis worsened if untreated. Even with treatment, endometriosis can recur, but some women with severe untreated endometriosis may be at risk of complications such as obstruction or blockage of the ureter (the tube between the kidney and bladder). These issues need to be considered when choosing the treatment options.

    Why & How is Endometriosis Staged?

    The amount of the endometriosis tissue present in the pelvis is usually described by doctors in a certain way to standardise their assessment for doctors and patients to consider surgical treatment and other treatment options. Many doctors use the classification provided by the American Society for Reproductive Medicine to assess the severity and extent of the disease. This system gives points based on where the endometriosis tissue is and how deep beneath the surface they extends to, so it can assist in staging the extent of endometriosis.

    How is Endometriosis Treated?

    There is no known cure for endometriosis; the aim of the treatment is to manage and improve the symptoms associated with the condition. This can be done medically and / or surgically. There are some life style changes that may also help to alleviate symptoms.

    Medical Treatment

    Medical treatment is simulating the hormonal background of either pregnancy or menopause, because symptoms associated with endometriosis, settle during those times. The available treatments are;

    • The combined oral contraceptive pill (OCP) or progestogen only pill (POP) (to mimic pregnancy). These treatments will reduce the number of menses so will reduce the pain and symptoms associated with endometriosis.
    • Gonadotrophin releasing hormones (GNRH)(to mimic menopause) this treatment is usually given for 6 months, during which you won’t have periods. Endometriosis tissue is expected to dry out when you are on treatment. The menopause symptoms that some women experience can be reduced by using a low dose hormone replacement therapy – or add-back as necessary (although this is a hormone based treatment is does not reduce the efficiency of the medication). This treatment offers temporary relief but some women experience benefit for many months/years even after treatment. Since using this treatment for long periods can make bones thin (osteoporosis) it is not used for longer periods.

    Surgical Treatment

    Endometriosis can be surgically removed and this is favourably done using key-hole surgery called a laparoscopy (see separate Laparoscopy patient information leaflet). Laparoscopy may provide symptom control and may improve fertility in some women. For mild endometriosis in particular, surgical excision does not provide any additional benefit over medical therapy in symptom relief or return of symptoms after treatment.

    Occasionally bigger operations are offered to separate adhesions and remove endometriosis cysts from ovaries. The women who need extensive and complex surgeries for endometriosis should be done in specialist centres, where they are discussed at regular multidisciplinary team meetings involving other specialist than gynaecologists (bowel surgeons, urologists, radiologists and pain specialists) and these specialists will decide that final surgery may need to be done by the appropriate team of surgeons with specific skills. As a last resort removal of the uterus, cervix, fallopian tubes and ovaries (hysterectomy and bilateral salpingo-oophorectomy – please see separate leaflet) may be offered, this is usually reserved for women who have completed their family and is often a technically difficult procedure. The important points to consider with surgical treatments are that there is no guarantee of symptom relief even with these extensive operations; the complications associated with surgery; permanent loss of fertility with some surgeries (e.g. hysterectomy or removal of both ovaries); and the fact that current research suggests that approximately 35% of women will develop recurrence of their endometriosis after surgery and may consider further and repeated surgery. Repeated surgery for endometriosis excision is potentially more risky with increase possibility of serious complications.

    Endometriosis and Fertility

    The relationship between endometriosis and fertility is not yet fully established or understood. There are many women with endometriosis who become pregnant without difficulty but endometriosis is found in 1 in 4 women who are undergoing investigations such as a laparoscopy for subfertility investigation (Cochrane 2002).

    There are no preventative surgical treatments that have shown to be effective to improve future fertility, yet for those women who are having difficulties in getting pregnant; consultation with an infertility expert is initially needed for particular advice for treatment for endometriosis.

    Frequently Asked Questions

    How do I get a referral to an Endometriosis Centre?

    Most commonly through your GP or Consultant.

    Once your referral has been received this will be triaged and an appointment will be sent to you.

    It is important to note that as an Endometriosis Centre we only see confirmed or suspected deep and severe cases diagnosed on Laparoscopy or Scan. Mild or moderate cases are seen in the general gynaecology setting, however depending on the clinical findings you may have further follow up in the endometriosis service.

    When will I have my surgery?

    This depends upon the severity of the disease; you may need further investigations which require the expertise of other specialists, i.e Colorectal or Urology (bowel and bladder). In these cases you will be referred to a local hospital who work alongside us, they will send you an appointment for consultation in the first instance. If you require further investigation such as Sigmoidoscopy (camera into the lower part of the bowel) this will discussed with you at consultation.

    Once a date for surgery has been allocated you will be contacted by the Admissions team. Any queries relating to your admission the team can be contacted on 0151 702 4475. Please leave a message with your name, hospital number and your contact details. Please do not leave a message for the Clinical Nurse Specialist as they are unable to organise operation dates.

    How do I contact the Specialist Nurse?

    If you attended the Endometriosis Centre you may have been given the contact number of the Specialist Nurse.

    The telephone number is 0151 702 4259, please leave a message and your contact details.

    You should only contact the Specialist Nurse if:

    1. You wish to ask further questions about your diagnosis or your treatment plan.
    2. You have been advised by the doctor to let them know of completed investigations.
    3. You have had your operation and have been seen or admitted back in a hospital due to problems or complications.

    Please do not contact the Specialist Nurse to routinely change your appointments as they are unable to do this (see Q1)

    Useful Addresses and Websites

    http://www.endometriosis.org

    http://www.endometriosis.co.uk

    http://www.womens-health.co.uk/endo.asp

  • Hysterectomy & The Menopause

    The leaflet is detailed below, or you can download the 'Hysterectomy & The Menopause' leaflet in PDF. 

    Important information for all women considering hysterectomy before menopause

    Hysterectomy and Menopause

    Many women under go hysterectomy (surgical removal of the uterus or womb) for various gynaecological reasons. These include period problems not improved by other treatments, fibroids, endometriosis, prolapse and malignant or premalignant changes of the uterus, cervix or ovary. Hysterectomy can either be total, where both the uterus and cervix are removed, or sub-total, where the main part of the uterus is removed but the cervix is retained (see hysterectomy leaflets).

    At the time of a hysterectomy, the ovaries may be left behind (conserved) or removed.

    If one or both ovaries are conserved at the time of hysterectomy, 3 scenarios are possible:

    1. Continuing normal ovarian function.

    The ovaries may continue producing hormones in their usual manner until the normal age of menopause (usually 51).

    In the years leading up to menopause, hormone production fluctuates and may cause symptoms of “premenstrual syndrome” (PMS). This is because PMS symptoms are due to the changing hormone levels, and not due to the presence of bleeding. Oestrogen deficiency symptoms, if they occur, would happen at the normal menopausal age (see related menopause leaflet).

    For further information on PMS, visit www.pms.org.uk

    1. Early ovarian failure-apparent

    Following a hysterectomy, the ovaries may stop producing hormones sooner than expected. This may mean that an earlier than usual menopause has occurred. This can happen immediately after surgery or a number of years later. Symptoms of oestrogen deficiency may be noticed (see related menopause leaflets). If this happens, it is very important to discuss these symptoms and the possible use of Hormone Replacement Therapy (HRT) with your Clinician.

    The importance of reporting symptoms of early ovarian failure:

    1. Oestrogen deficiency symptoms can be unpleasant and effective treatments are available.
    2. Oestrogen is very good for maintaining bone strength. If the production of oestrogen is lost at an early age (before 45 years), an increased risk of Osteoporosis (bone thinning) can occur. For further information on osteoporosis, visit: nos.org.uk
    3. Oestrogen also protects the heart and blood vessels. Loosing Oestrogen production – particularly before age 45 – can increase the risk of Cardiovascular Disease.
    1. Early ovarian failure-silent

    In some women, the conserved ovaries may fail earlier than usual, but, falling oestrogen levels do not always cause noticeable menopause symptoms.

    It is therefore suggested that

    Following a hysterectomy with one or both ovaries conserved before the age of 45, a blood test can be taken approximately once per year, to check if an early silent menopause has occurred. (If menopausal symptoms have developed, blood tests are not required).

    Detecting silent early ovarian failure ensures an opportunity to address the long term affects of menopause and consider preventative treatments.

    If the ovaries are removed  (Oophorectomy) at the time of hysterectomy, a sudden loss of ovarian hormone production, in particular oestrogen, occurs.

    This sudden, “surgical menopause” may cause oestrogen deficiency symptoms within a few days of surgery.

    These symptoms include hot flushes and sweats. HRT may then be considered for symptom control and/or for its protective effect on bone and heart.

    HRT Following Hysterectomy

    HRT is usually recommended if the operation causes an early menopause (before 45 years) because there is a significantly increased risk of Osteoporosis and Cardiovascular Disease.

    If HRT is commenced following hysterectomy, it is usually prescribed as an oestrogen only preparation. The particular type of prescription is tailored to suit individual needs and is chosen after consideration of personal preference and any past medical history. HRT using a combination of oestrogen and progestogen (which is recommended when the uterus is still present) is often used after a hysterectomy when widespread endometriosis is present.

    Endometriosis is the presence of deposits of the lining of the uterus (endometrium) outside the uterus, e.g. on the bladder, bowel and other organs in the body.

    These deposits are sensitive to the hormones produced by the ovaries. After hysterectomy and removal of the ovaries, there have been reports of endometriotic deposits being stimulated following oestrogen-only HRT.

    It is thought that oestrogen combined with progestogen HRT is less likely to cause stimulation of these deposits.

    For further information on endometriosis, please visit www.endo.org.uk or see endometriosis leaflets.

    Sub-Total Hysterectomy

    If the main part of the uterus has been removed but the cervix left in place, it is currently uncertain whether HRT can be given in the form of oestrogen-only or wether oestrogen combined with progestogen is necessary.

    The slight concern of using oestrogen-only HRT, is that if there is endometriumin the cervical canal, this could become thickened (potentially unhealthy) from oestrogen stimulation.

    This thickening can be prevented by adding progestogen.

    To determine if progestogen is required, it may be suggested to use oestrogen combined with cyclical progestogen for a 3 month trial after hysterectomy. If there is monthly bleeding in this time, it means that endometrial cells are present and are responding to the hormones; so both oestrogen and progestogen should be used thereafter. (These hormones can however be given together continuously to avoid monthly bleeding). If there is no bleeding in the first 3 months, then oestrogen can be safely given on its own.

    If HRT is commenced because of an early menopause after surgery, it can be continued until the age of 50 years without concern about any increased risk of breast cancer.

    At around the age of 50, a decision regarding whether or not to continue HRT should then be made.

    This is the same decision that any woman becoming menopausal at the normal menopausal age would make, i.e. whether or not to commence HRT.

    References:

    British Menopause Society

    (www.thebms.org.uk)

    Clinical Knowledge Summaries

    www.cks/patientinformation

    Menopause Matters

    www.menopausematters.co.uk

    National Institute for Health and Care Excellence (NICE) 2015 Menopause: Diagnosis and Management

    www.nice.org.uk/guidance/ng23

    www.patient.co.uk/menopause

    Royal College of Obstetricians and Gynaecologists (RCOG) Menopause Patient Information Hub

    www.rcog.org.uk/en/patients

  • Hysteroscopy Clinic. After Care Advice and Information Following Outpatient

    The leaflet is detailed below, or you can download the 'Hysteroscopy Clinic. After Care Advice and Information Following Outpatient' leaflet in PDF.

    While You Recover, You May Experience:

    Cramping that’s similar to period pain – this should pass in a few days and you can take regular painkillers such as paracetamol or ibuprofen if you have no contraindications to these painkillers.

    Spotting or bleeding – this can last up to a couple of weeks ; use sanitary towels rather than tampons until your next period to help reduce the risk of infection

    Returning to normal activities - Most women feel they can return to normal activities, including work, the day after having a hysteroscopy.

    You can have a shower the same day or the follow day.

    You should avoid sexual intercourse for a week, or until the bleeding stops- this will help reduce the risk of infection.

    If you’ve had a Mirena device fitted – it can take up to 6 months for period problems to settle. In this time you are likely to get unpredictable, light bleeding or spotting, this may be on most days. After 6 months, most people only get a day or two of spotting each month, or sometimes none at all.

    We also recommend you attend your GP practice 6 weeks following insertion of Mirena for your Practise nurse to check Mirena threads are visible; this is to ensure Mirena has not expelled.

    Getting Your Results If We Have Taken a Biopsy

    We will write to you once we have received your results. This is usually within 6 weeks.

    If you have any other queries or concerns about your treatment, please contact our Hysteroscopy Nurses on 702 4147 or 702 4319

  • Having a LLETZ Treatment (Loop Excision)

    The leaflet is detailed below, or you can download the 'Having a LLETZ Treatment (Loop Excision)' leaflet in PDF.

    You will be offered this if you have:

    • A moderate or severely abnormal smear
    • Abnormal glandular cells on your smear
    • A biopsy that shows CIN 2 or 3
    • A biopsy that shows abnormal glandular cells
    • Your abnormal cells are not visible on the outside of your cervix

    This can be offered at the first visit. The procedure will be explained, and you will be asked to sign a consent form. A colposcopy examination will then be carried out as above. Occasionally it may be more appropriate to have the procedure under a general anaesthetic but if this is the case, your clinician will explain everything and arrangements for a future day case admission will be made.

    We advise all women with coils who are due for loop excision to avoid sexual intercourse or use barrier contraception (e.g. condoms) for 7 days prior to treatment just in case the coil needs to be removed (FFPRHC 2006) Please see section later.

    What actually happens?

    A fast-acting local anaesthetic will be given into your cervix. Whilst it is taking effect the rest of the equipment will be set up: a sticky pad is attached to your thigh to ensure a safe return path for the electric current being used to avoid injury and a plastic tube attached to the top of the speculum to circulate cool air.

    Some of the anaesthetic can sometimes make you feel a little strange: it can make you heart beat faster and your legs feel wobbly. If this happens please do not panic, it is quite normal and will settle quite quickly. Breathe normally and don’t worry about shaky legs.

    Once we are sure that the anaesthetic is working, a thin electrical wire loop is used to remove the abnormal area – hence the name. The area is then sealed to stop it bleeding with another type of electrical instrument. It is a very safe procedure and takes about 15 minutes.

    What if I have a coil? (Intra-uterine contraceptive device, IUS, IUCD)

    You will be offered the choice of having the coil removed or leaving it in. Both options have associated problems.

    If the coil is left in the strings may get cut by the loop. This will not have any immediate effects but may cause difficulty when the coil needs to be removed.

    Taking the coil out can only be done if there is no chance of you getting pregnant. Hence you will be asked whether you have had sex in the last 7 days. If there is any doubt or concern, the treatment will be delayed until the coil can be safely removed. If it is taken out, it can be replaced 6 weeks later but this is not done in the hospital.

    We advise all women with coils who are due for loop excision to avoid sexual intercourse or use barrier contraception (e.g. condoms) for 7 days prior to treatment just in case the coil needs to be removed (FFPRHC 2006).

    Is the treatment painful?

    It is usually painless or minimally uncomfortable because of the local anaesthetic used. Some women experience period type pains for a day or two, but this will settle with usual over the counter painkillers.

    Does the treatment have any side effects?

    LLETZ treatment is generally very safe but as with all surgery there can be complications:

    • Up to 50% of women will experience 10 days of bleeding and discharge which may be moderate to heavy
    • Many experience pain for a day or two afterwards
    • Bleeding is more likely if you get an infection in the raw area on your cervix which takes about 4 weeks to heal
    • If you do get an infection there will be a smelly discharge or increased bleeding. In this case contact your GP for antibiotics
    • In very rare cases the bleeding is severe, and the woman needs to be admitted to hospital.
    • Bleeding can occur 2 weeks after the procedure as a result of bacteria living in the vagina causing the blood vessels to open up.
    • Some women notice a difference in the timing and length of their periods afterwards
    • There is a small chance that as the cervix heals it scars up making the canal narrow and makes it difficult for the blood to escape when you have a period. This is called stenosis.
    • Research suggests that with a loop of less than 10mm deep there is no associated increase in the chance of pre-term labour or pre-term rupture of the membranes. There may be a small increase in miscarriage before 20 weeks, but this is small and controversial. Deeper and repeat treatments could increase your chance of premature delivery.
    • We aim the treatment to remove all the abnormal cells but occasionally some get left behind (residual abnormality). This is why it is important to attend for your follow up smear which will recognize if any abnormal cells and HPV virus are still present.
    • Damage to other tissues is very rare
    • Loop excision does not affect how easy or otherwise it is for you to get pregnant

    Please note that some travel insurance companies will not provide you with health insurance following this procedure. You may wish to rearrange your colposcopy treatment appointment if you are going on holiday or flying within four weeks of the treatment date.

    To keep the risk of infection as low as possible you MUST AVOID:

    •  Sexual intercourse for 6 weeks
    • Using tampons for 6 weeks
    • Swimming for 6 weeks
    • Taking long soaks in the bath for 2 weeks (shower instead)
    • Undertake excessive exercise for 2 weeks

    If you have any problems relating to a treatment you can speak to a nurse colposcopist by telephoning:

    0151 702 4266 – Crown Street Site

    0151 529 3378 – Aintree site

    (These lines are ONLY for post treatment issues)

    Can I bring someone with me?

    Yes of course. It is easier to have someone to take you home afterwards although you are safe to drive. You should take it easy for the rest of the day.

    What about work?

    You can go back to work the day after as long as it does not involve lifting or strenuous activity. If so, you may need to take a few days off.

    What if I am due to go on holiday?

    We recommend waiting until after a holiday to have treatment because of the restriction with swimming and sex as outlined above. We can re-book you to have your treatment at a later date. Please do not worry that this will cause you problem to get worse: it won’t. If you are pregnant we wait until you are 3 months post-delivery before performing treatment.

    Please note that some travel insurance companies will not provide you with health insurance following this procedure. You may wish to rearrange your colposcopy treatment appointment if you are going on holiday or flying within four weeks of the treatment date.

    What happens next?

    The removed tissue is sent to the lab and we write to you with the results usually within 6 weeks. We do not give results over the telephone. Sometimes more treatment is needed so we will ask you to return to the clinic to talk through your choices.

    You will be asked to have a smear 6 months post treatment to ensure that there are no abnormal cells or HPV virus left behind. This may be done in the hospital clinic or at your GP surgery. For 95% of women this will be all that is needed.

    For a few women the problem returns, and you have to have a second treatment. For about 3 in every 10,000 treated women, cancer can still develop and that is why it is so important to have follow  up cervical screening tests.

    Very rarely women may need to have a hysterectomy, but this will all be discussed when and if necessary.

     

  • Anti-D Immunoglobulin

    The leaflet is detailed below, or you can download the 'Anti-D Immunoglobulin' leaflet in PDF.

    On routine testing of your blood it has been found that your blood group is Rhesus Negative.  This is not rare, although a small percentage of the population are Rhesus Negative, the remainder being Rhesus Positive.

    Blood naturally passes from your pregnancy into your blood stream which is Rhesus Negative.  If the blood of your pregnancy is Rhesus Positive you may form a group of substances which will work against positive blood, medically known as antibodies.

    It is important that as you are or have been pregnant you receive an injection called anti-D immunoglobulin.  If it is not given it may cause problems in future pregnancies. In certain circumstances and depending on how many weeks pregnant you are, anti-D may not be required. This will be discussed with you during your consultation.

    With your consent the injection will be given to you by a nurse during your procedure.

    Anti-D immunoglobulin is a blood product, produced from blood plasma taken from carefully selected donors.  Due to the potential risk of infection the donors and their plasma are carefully screened.  Further screening during the manufacture of anti-D immunoglobulin also takes place.  Although rare, the risk of infection transmission cannot be completely eliminated.

    Allergic reactions to anti-D immunoglobulin are rare.  However, we request that you remain in the Centre for minimum of twenty minutes following the injection.

    Side effects are uncommon however, should you feel unwell following the injection please contact the Centre, your GP or local A&E Department.

    Should you require any further information please ask a member of staff.  A leaflet with more detailed information regarding anti-D immunoglobulin is available on request or go to www.medicine.org.uk 

    Liverpool Women’s Hospital contact telephone numbers:

    Bedford Centre 0151 708 9988 extension 1130

    Gynaecology Emergency Department 0151 702 4140

  • Vulval Rapid Access Clinic

    The leaflet is detailed below, or you can download the 'Vulval Rapid Access Clinic' leaflet in PDF.

    Why Am I Attending Clinic Today?

    Your doctor thinks you have an area on your vulva that he or she is concerned might be abnormal, and could be a type of cancer.

    What Is Vulval Cancer?

    The vulva is the skin and fatty tissue between the upper thighs of women, from the area of the anus to about an inch below the pubic hairline.

    Cancer of the vulva most often affects the two skin folds (or lips) around the vagina, known as the labia.

    Vulval cancer is rare. If found early, it has a high cure rate of around 90%

    Who Is Affected?

    Vulval cancer can affect women of all ages but it more common in women aged 65 – 75. Vulval cancer may be related to genital warts or a sexually transmitted disease caused by the human papillomavirus (HPV).

    What Are The Signs Of Vulval Cancer?

    • Vulval itching that lasts more than a month
    • A cut or sore on the vulva that won’t heal
    • A lump or mass on the vulva
    • Vulval pain
    • Bleeding from the vulva (different from your usual monthly bleeding)
    • Prolonged burning or stinging sensation in the vulval area
    • Any change in size, colour, or texture of a birthmark or mole in the vulval area

    How Is Vulval Cancer Diagnosed?

    If there is an abnormal area on the vulva, the doctor may take a biopsy. Firstly local anaesthetic is injected to numb the area, then a small piece of skin is taken and sent to the laboratory where it is examined under a microscope.

    What Are The Benefits Of Having The Test?

    This test will tell us whether you have a vulval skin condition or if you have cancer. A sample in an outpatient setting using a local anaesthetic thereby avoiding general anaesthetic and admission to hospital.

    What Are The Risks Associated With This Test?

    Bleeding – occasionally you may have some bleeding from the area.

    Pain – there will be some local discomfort or pain in the area and simple painkillers such as paracetamol can be taken.

    Infection – you will be given advice on how to keep the area clean after the procedure, occasionally an infection can develop, if this does occur then it can be treated with antibiotics.

    Failure to obtain a biopsy – occasionally we may not be able to obtain a biopsy – because it is too uncomfortable or for technical reasons.  

    What Alternative Do I Have?

    A biopsy is the only way to find out if you have vulval cancer and as an alternative the biopsy can be taken during a general anaesthetic.

    Will I Get My Biopsy Result Today?

    No, the biopsy result will not be available for approximately 10 days.

    What Will Happen Next?

    Depending on the result of the biopsy we will either telephone or write to you to discuss it and arrange any further tests, appointments or operations for you.

    We will also write to your GP to keep him/her informed of our findings.

    What If The Biopsy Is Normal?

    You may be discharged and no further follow-up arrangements will be required.

    Sometimes the biopsy shows there is a condition present called lichen sclerpsis (please request the “Lichen Sclerpsis” leaflet for more detailed information); it is treated with moisturising creams and strong steroids. Although this is a benign (non-cancerous) condition, it will require long-term monitoring and this will be arranged for you at the hospital.

    How Is Vulval Cancer Treated?

    Vulval cancer is usually treated with surgery. The type of surgery depends on the size, depth, and spread of the cancer. Some people may also need radiation therapy.

    If you have any queries or concerns please phone:

    Liverpool Women’s NHS Foundation Trust

    Mon – Fri 9am to 4pm.

    0151 702 4236 to speak to the Rapid Access Clinic Admin Support.

    Or speak to the nursing staff in the Emergency Room on 0151 702 4438

    Or telephone your GP.

    Liverpool Women’s is a smoke free site. Smoking is not allowed inside the hospital building, grounds, car parks or gardens. If you would like advice about stopping smoking please ask a member of staff.

  • Preventing DVT & Pulmonary Embolism

    The leaflet is detailed below, or you can download the 'Preventing DVT & Pulmonary Embolism' leaflet in PDF.

    A blood clot in the vein is a common complication of a hospital stay. This hospital makes every effort to prevent this problem and it is very important that you read and understand the information in this leaflet.

    We have written this leaflet to explain how the risk of developing venous thromboembolism can be reduced.

    It does not replace explanations and information given to you by our staff but we hope you will find it a helpful guide to use before, during and after your stay in hospital. If you have any questions or need further information, please ask.

    What Is Deep Vein Thrombosis (DVT)?

    This is a blood clot that forms within a deep vein in the leg or pelvis. This can be painful and cause leg swelling.

    After gynaecological surgery, 1 in 5 patients develop a DVT, if not treated.

    A pulmonary embolism may occur if part of the clot breaks off and passes into the lungs. This can be a very serious condition, which can cause pain, breathlessness and lack of oxygen in the blood. Pulmonary embolism causes 25,000 deaths each year in hospitalised patients in the UK.

    Why Are Hospital Patients At High Risk Of DVT?

    During normal daily activity, blood is kept flowing freely through the leg veins by contraction of the calf muscles. This prevents clot formation.

    Staying immobile in bed for a long period of time causes a risk of blood clots forming in the leg veins, particularly after an operation.

    There are a number of conditions that increase the risk further, which include

    • Pregnancy
    • Medicines such as birth control pills, hormone replacement therapy and tamoxifen
    • Obesity
    • Previous episode of DVT or PE in yourself or a member of your family
    • Abnormal blood clotting
    • Heart failure
    • Kidney failure
    • Cancer

    Please ask your hospital doctor nurse or midwife if you wish to discuss your own personal risk factors.

    What Can I Do To Reduce The Risk Of Developing DVT And PE?

    Before coming into hospital

    • Keep mobile – move around as much as possible in the weeks leading up to your surgery

    When you come into hospital

    Your clinical team will assess your risk of VTE and consider what can be done to reduce this. 

    Measures to reduce the risk include:

    • Mobilising (moving around) – as soon as possible, after surgery or treatment, is important and in many cases will be the only measure you need to take to reduce your risk of VTE.
    • Special stockings – have been shown to reduce the risk of DVT. These are called anti-embolism or graduated compression stockings. If your team thinks stockings would be helpful you will be fitted with a pair.
    • Medication – If we think you are at fairly high risk of VTE, then we may give you some medication which stops the blood from clotting too quickly. The drug we normally prescribe is given by an injection under the skin once or twice a day.

    If you are already taking anticoagulant medications such as Warfarin then we ill only prescribe these other drugs if you have to stop taking your Warfarin for any reason. Please remember to tell your doctor if you are already taking an anticoagulant medication

    After I Go Home

    If you are prescribed an anticoagulant this may be stopped when you are discharged or you may need to continue for a while at home. If you have had stockings fitted you should continue to wear these until you are fully mobile.

    Try not to become dehydrated and keep as active as you can.

    What Are The Possible Symptoms Of VTE And What Should I Do If I Have Them?

    If you have:

    • Unexplained pain and swelling in your legs
    • Chest pain when you take a breath
    • Breathlessness
    • Coughing up blood

    Seek medical advice straightaway either from your GP or hospital

    If you develop DVT or PE, anticoagulant medication (medication to thin your blood) is very effective at treating the problem.

    Who Can I Contact For More Information?

    If you have any questions or would like any more information, please just ask your doctor, nurse or pharmacist or in an emergency, for advice contact the:

    Gynaecology Emergency Department

    Tel: 0151 702 4140

    Maternity Assessment Unit

    Tel: 0151 702 4413

    Liverpool Women’s is a smoke free site. Smoking is not allowed inside the hospital building, grounds, car parks or gardens. If you would like advice about stopping smoking please ask a member of staff.

  • Hysteroscopy

    The leaflet is detailed below, or you can download the 'Hysteroscopy' leaflet in PDF.

    What is a Hysteroscopy?

    Hysteroscopy is a procedure carried out to look at the inside of the womb.  A hysteroscope, which is a type of camera, is inserted via the vagina into the neck of the womb.  The instrument is then attached to a light source to allow the person performing the procedure the opportunity of examining your womb.

    What are the benefits of having this surgery?

    This surgery will enable the surgeon to view the internal structures of the womb without the need for a more lengthy operation requiring an incision (cut) to the abdomen.  It is also possible to remove polyps, take samples of the lining of the womb during the procedure.

    Do I need anaesthetic?

    Not always.  Many patients are able to have this procedure carried out in clinic.  However, not all patients are suitable to have it done as an outpatient without anaesthetic and many doctors will recommend that a general anaesthetic is used as they are able to have a clearer look without causing discomfort.  If you do require admission it is usually done as a day case, and the procedure lasts approximately 10 – 15 minutes.  The doctor will be able to discuss in clinic which is the most suitable for you.

    What alternatives do I have?

    This depends on the reasons for having the investigation.  Other possible investigations may be an ultrasound scan or surgery to view the pelvis.  The doctor would be happy to discuss any alternative investigation or treatment if they are applicable to your particular case.

    What happens following Hysteroscopy?

    Sometimes small samples or biopsies are taken; you will be told if this is the case.  These will be sent to the laboratory for examination.  You will be advised of the results as soon as they are available.  If the doctor thinks you require medication, he will prescribe this for you before you leave.

    If it is necessary to carry out any further surgery or investigations, the doctor will advise you of this before discharging you.

    On discharge you are advised to rest for 2 – 3 days.  Some bleeding may be experienced, though this should be minimal.

    Pain is usually mild and simple painkilling tablets, such as Paracetamol are effective in most cases.

    What are the risks involved with a Hysteroscopy?

    A Hysteroscopy is a very safe operation, which is performed very frequently.  However on very rare occasions perforation of the womb (making a hole in the wall of the womb) may occur. This may be noted at the time of surgery and may not require further action.  However a small stitch or a more involved operation, depending on the extent of the perforation, may be required. This will be done whilst you are under anaesthetic and will result in you needing to stay in hospital for a longer period, so that you can be observed closely.

    Infection is a possible complication, however it is rare. If this should happen you may develop a foul smelling discharge, abdominal discomfort and a temperature. If you have any of these symptoms, seek advice from your GP.

    An extremely rare complication is weakening of the fibres and muscles of the cervix (neck of the womb). If this does happen it can increase the risk of late miscarriage.

    It is important to note that there is a small possibility that the surgery cannot be completed. This depends on findings at the time of surgery.

    Retained tissue

    Any tissue taken at the time of your operation will be sent for examination and your Consultant will be informed of the result.  Following investigation the tissue will be disposed of in accordance with health and safety. With your permission this may be useful for research or teaching purposes.

    The staff are always prepared to discuss these and any other issues with you. If you have any concerns following surgery contact The Emergency Room at Liverpool Women’s Hospital on 0151 702 4140.

    For further information visit

    http://www.2womenshealth.co.uk/

     

    Please note that Liverpool Women’s NHS Foundation Trust is a smoke free site. Smoking is not allowed inside the hospital building or within the hospital grounds, car parks and gardens. Staff are available to give advice about stopping smoking, please ask your nurse about this.

  • What to bring with you for your miscarriage management

    The leaflet is detailed below, or you can download the 'What to bring with you for your miscarriage management' leaflet in PDF. 

     

    Why have I been given this leaflet?

    This leaflet is for women who have suffered a miscarriage and have chosen medical or surgical management that means they will be spending time in the hospital with us.  We appreciate that this is a difficult time and so have come up with some advice on what to bring with you when you come in to us. 

    What should I bring for my stay in the hospital?

    Although we do not anticipate most women will need to stay overnight it is best to be prepared.  We would advise you to bring an overnight bag including toiletries, fresh underwear and nightwear such as dressing gown, slippers and pyjamas.

    Sanitary pads will be provided on the ward however you may wish to bring your own which you are comfortable wearing.

    There are no televisions on the ward but there is accessible WiFi. Most ladies like to bring a Tablet/iPad with pre-downloaded films, games or music. Please don’t forget your earphones. Magazines or books or puzzle books etc. can also be purchased in the onsite WHSmith.

    Please bring with you any regular medication that normally take and give them to the nurse on admission. You will be provided with these and/or painkillers if and when you require them.

    I’ve opted for medical management is there anything else I need to know before I come in?

    You can usually eat and drink as normal unless you are told otherwise on the day. Meals will be provided for you but you may like to bring your own drinks and snacks.  Please not there aren’t any fridge storage facilities. There is a WHSmith, a Deli Café and a Starbucks onsite if you wish to purchase refreshments or snacks. It is advised that you don’t leave the ward once treatment has started so it may be better if your support person goes on your behalf. Please advise staff on admission of any specific dietary requirements you may have e.g. gluten free/vegetarian etc. and staff will be able to accommodate as best as possible

    You can bring someone with you for the day. Unfortunately there are currently no facilities for them to stay with you overnight.

    I’ve opted for surgical management is there anything else I need to know before I come in?

    You will have been asked not to eat or drink anything before your surgery so you will be provided with hot/cold drinks and light diet post-surgery but you may wish to bring your own food or drinks for afterwards. Unfortunately there are no fridge storage facilities. Please advise staff on admission of any specific dietary requirements you may have e.g. gluten free/vegetarian etc. and staff will be able to accommodate as best as possible

    It is advised that you bring with you a fully charged mobile phone so you can contact someone to collect you when you are ready for discharge

    We ask that you do not wear any jewellery, nail varnish or false eyelashes for your surgery so please remove such items before coming in.

  • Chlamydia Trachomatis

    The leaflet is detailed below, or you can download the 'Chlamydia Trachomatis' leaflet in PDF.

     

    What is Chlamydia?

    Chlamydia is the most common bacterial sexually shared infection in the country. It affects both men and women. 7 out of 10 people with Chlamydia have no symptoms and will be unaware that they have Chlamydia.

    Young people are particularly at risk if they have ever been sexually active.

    How is Chlamydia passed on?

    It can be passed on in the following ways:

    • Having sex with someone who has Chlamydia. This may have been recently or many months or years earlier.
    • By a mother to her baby at birth.
    • By passing the infection on fingers from the genitals into the eyes.

    How common is Chlamydia?

    • About 1 in 20 sexually active women in the UK are infected with Chlamydia.
    • It is most common in women under the age of 25.

    What symptoms will I have?

    As already mentioned, most people will not have symptoms. If they do, they can include:

    In women

    • An unusual vaginal discharge
    • Bleeding after sex
    • Bleeding between periods
    • Abdominal or pelvic pain
    • Pain during sex
    • The need to pass urine more often or pain when passing urine

     In Men

    • Discharge from the penis which may be white/cloudy and watery
    • A burning sensation when passing urine
    • Swollen and/or painful testicles

     In women and men

    • Appendicitis
    • Upper abdominal pain
    • Painful swelling and irritation in the eyes
    • Inflamed joints
    • Occasionally a rash on the soles of the feet and genitals

    How can I find out if I have Chlamydia?

    You can have a swab taken which will show whether or not you have this infection. In some places, a urine test is available to detect Chlamydia infection.

    Can Chlamydia be treated?

    Chlamydia can be easily treated with antibiotics.

    Your sexual partner/partners will also need to be treated with antibiotics to prevent you becoming re-infected.

    Why should I have treatment if I have no symptoms?

    •  You can pass the infection to your sexual partner even if you do not have symptoms
    • The infection may spread and cause complications

    What effect can Chlamydia have on me?

    If left untreated, Chlamydia can cause serious problems.

    Some women with Chlamydia (up to 1 in 5) may suffer from Pelvic Inflammatory Disease (infection in the lower abdomen).

    This can lead to:

    •  Pain
    • Ectopic pregnancy (when a pregnancy develops outside the womb)
    • Infertility (difficulty getting pregnant)

    Where can I be treated?

    A Chlamydia test is available at:

    •  Your GP surgery
    • Family Planning clinic
    • Well Women’s clinic
    • Genito-urinary Medicine clinic (GUM clinic)

    The local GUM clinic is held at the Royal Liverpool University Hospital, telephone: 0151 706 2621.

     

    Liverpool Women’s is a smoke free site. Smoking is not allowed inside the hospital buildings, grounds, car parks or gardens. If you would like advice about stopping smoking please ask a member of staff.

  • Your Colposcopy Appointment

    The leaflet is detailed below, or you can download the 'Your Colposcopy Appointment' leaflet in PDF.

    Welcome

    Welcome to the colposcopy service for the Liverpool Women’s NHS Foundation Trust.

    There are two units, one based at the Liverpool Women’s Hospital and one at Aintree Hospital next to the LWH gynaecology out-patient department.

    The information in this leaflet is intended to be a general guide to the colposcopy service so please be aware that not all of the information will apply to you.

    You will be given an opportunity to talk to the colposcopist (specialist doctor or nurse) and ask any questions before having your examination. You can also get further information from your GP or practice nurse.

    Every year thousands of patients miss their hospital appointments costing the NHS money, delaying treatment and increasing waiting times for other patients.

    If you are unable to attend your appointment for any reason, please contact the Access Centre on 0151 702 4328.

    What is colposcopy?

    A colposcopy is an examination of the cervix (neck of the womb) using a special microscope called a colposcope which allows us to look more closely at your cervix than during a smear test. The colposcope does not go inside you. The only thing that does go inside is the speculum, the same instrument used when you have a smear test. We spray a dilute solution of vinegar onto your cervix which shows up any abnormal cells and take a digital image of what we see which is kept on your electronic records.

    Why do I need a colposcopy?

    There are many reasons why you may have been referred to the unit. You might have had:

    • An abnormal smear
    • An inadequate smear
    • An unusual looking cervix
    • A cervical polyp
    • Bleeding with sexual intercourse

    Please note that colposcopy does not investigate bleeding between periods, heavy periods or pelvic pain so please don’t expect your Colposcopist to answer questions relating to these symptoms.

    We advise all women with coils who may require a loop excision to avoid sexual intercourse or use barrier contraception (e.g. condoms) for 7 days prior to treatment just in case the coil needs to be removed (FFPRHC 2006) Please see section later.

    Do I need to contact you before my appointment?

    Only if you wish to change your appointment. Then call the Access Centre on 0151 702 4328 NOT the colposcopy office.

    We still want to see you even if you are on your period, are pregnant, have a vaginal infection or have concerns about a past experience. We may alter what we do during the consultation but we still want to talk to you.

    If you are taking the combined oral contraceptive pill you could take packs back to back without a break to avoid having a period.

    Colposcopy is safe in pregnancy and if further examinations are necessary we will book them accordingly.

    What is Human Papilloma Virus (HPV)?

    Your cervical screening test may show the presence of HPV. This is an extremely common virus which you could have picked up years before. Anybody who has ever been sexually active is at risk of contracting HPV. It is very common and at least 8 out 10 women have the virus at some time. In time, most women’s bodies reject the virus but some do not. If you smoke, your body will be less able to reject the virus so it may cause more problems with abnormal cells. This could be another good reason for you to give up smoking.

    Further information can be found on the Jo’s Cervical Cancer Trust website: www.jostrust.org.uk

    What is going to happen at my appointment?

    At Aintree you will book in within the department and wait until you are called to the room.

    At Crown Street you will book in using the electronic book in system. Please watch the screen as your name and room number will appear when you are needed. Please proceed to the room indicated as quickly as possible.

    PLEASE GO TO THE TOILET BEFORE YOU GO DOWN TO THE CLINIC as there are no toilets in the colposcopy department.

    On both sites you will be asked to confirm your details with the nurse before entering the room. You will be introduced to the nurses and your Colposcopist. Firstly you will be asked some questions about your reason for attending; this is called ‘taking a history’. You will be asked for the result and date of your last smear test and the first day of your last period so please make sure you have these details to hand. If you take any tablets or medicines, the clinician will need a list of those too so please bring one with you. The clinician will answer any questions you may have and explain what is going to happen. If you need treatment, this will be explained and you will be asked to sign a consent form.

    You will then get changed and have your colposcopy examination when the clinician will see what the problem is and what needs to be done. There are several possible things that might happen during the appointment:

    • There may be nothing abnormal to see. You may be advised to have a cervical screening test repeated. This could be at any time between 12 months and 5 years depending on the initial problem
    • Your colposcopist may see some very minor changes and will take some punch biopsies. These are tiny pinches of skin and do not usually need local anaesthetic. They have no harmful effects but you should observe the advice on the page entitled ‘Having a Biopsy’
    • There may be some abnormal cells to see which you may be advised to have treated. This is called a large loop excision of the transformation zone (LLETZ) or loop excision. This is usually done under local anaesthetic and can be done at the time or re-arranged for another day, it’s up to you. Please see the page entitled ‘Having a Loop Excision’
    • There may be some abnormal tissue which you are advised to have treated under a general anaesthetic. This doesn’t mean that the problem is more serious. It may be because the area is difficult to get at, or goes deeper into the cervix. If you do have to have this done we will aim to get you in as day case as soon as possible (within 8 weeks)

    Whatever happens during your appointment it will all be explained to you and you will have the chance to ask questions. You are welcome to bring someone with you for support and we encourage you to eat normally before you attend and take any regular medication. We recommend that you try to arrange for someone to care for your children whilst you attend your appointment. If this is not possible please supervise them at all times. It is unadvisable to have small children with you if undergoing treatment.

    Any results will be sent to you by letter within 6 weeks of your visit. The letter will contain a plan for follow up if needed or will tell you if you have been discharged. We do not give results out over the telephone so please do not ask or call.

    Cervical Ectopy

    Ectopy, also called ectropion and erosion is a common finding especially in the young (<30 years old) and if you take the oral contraceptive pill. It is rare after the menopause. It is a harmless change where the ‘soft’ (glandular) cells that usually lie within the cervical canal and womb lining appear on the outside of the cervix. This makes the cervix look very red and these cells often bleed easily, especially with intercourse because they are very soft and fragile.

    In most cases an ectopy goes away on its own. You only need treatment if your symptoms are severe and this is done by cauterization also called coagulation. This process destroys the soft cells and in time they are replaced by the firmer flat (squamous) cells which don’t bleed as easily. Even with treatment, the condition can recur.

    We do not offer coagulation treatment at your first visit. Coagulation can only be carried out AFTER biopsies are done to rule out any abnormal cells that may need a different treatment. If you decide you want treatment for your symptoms you will have the biopsies done at the first visit and then called back to have the treatment at another time usually 3 months.

    Please read the section entitled ‘Having Coagulation Treatment’.

    Cervical Polyps

    These are very common and look like little skin tags with a thin stalk. Most of the time they are harmless but they can cause bleeding. They can be easily removed by twisting the stalk and pulling them off; anaesthetic is not needed. Sometimes cautery is needed to control bleeding if the stalk is thicker. Anything removed is sent to the lab to ensure that it contains no abnormal cells. You will be informed of the results by letter within 6 weeks.

    Having a Biopsy

    A biopsy is a tiny pinch of skin cells taken from the cervix and sent to the pathology lab to find out if there are any abnormal cells present. If they are present the lab will be able to grade them so a plan for treatment can be made if necessary. Usually more than one biopsy is needed and they will be taken at your appointment, you don’t usually have to make a return visit to have them done. Any bleeding will be stopped at the time by applying a special paste or using a silver nitrate stick.

    Biopsies have no harmful effects but you are advised:

    • To avoid sexual intercourse for 2-4 days
    • Avoid Using tampons for 2-4 days
    • Avoid Soaking for a long time in the bath for 2-4 days
    • Avoid Excessive exercise for 2-4 days
    • You may have a moderate blood loss for up to 6 days
    • 1 in 20 women experience pain which may last for 2 days and may require paracetamol to settle

    You will be informed of the results by letter within 6 weeks

    What might the biopsy show?

    • No abnormal cells
    • Inflammation or HPV – this is regarded as a normal finding
    • CIN stands for Cervical Intra-epithelial Neoplasia and is the medical term used to describe cell changes in the cervix that have been confirmed by biopsy. They are graded on a scale of 1 to 3. THEY ARE NOT CANCEROUS
    • CIN 1 – this means 1/3 of the cells in the affected area are abnormal. They may be left to return to normal or you may be offered treatment if they are still abnormal after 2 years.
    • CIN 2 – this means 2/3 of the cells are abnormal and treatment is usually offered to return these cells to normal
    • CIN 3 – this means all the cells in the area are abnormal. Treatment will be needed to return these cells to normal.
    • Only vary rarely will a biopsy show cell changes that have already developed into cancer

    Having Coagulation Treatment

    This will be offered to you if:

    • You have CIN 1 changes on your cervix that have not resolved over the past 24 months
    • You have an ectopy that is causing troublesome bleeding with sexual intercourse and you have had biopsies that have confirmed no major abnormality.

    Hence this treatment will never be offered on a first visit.

    The procedure will be explained and you will be asked to sign a consent form.

    You will then undergo a colposcopy so the clinician can see clearly where the area of concern is. Sometimes we use iodine to show up the area.

    A fast acting local anaesthetic can be used if you have a large area although smaller areas can be treated without. A heated probe is applied to the cervix for 20 seconds at a time until the whole area has been treated. You will then be allowed to get dressed again.

    You should be fine to drive home if needed and do not need to take time off work.

    After treatment you:

    • Will get a blood stained sometimes black discharge for up to 4 weeks. During this time you MUST NOT:
    • have sex
    • use tampons
    • go swimming
    • undertake excessive exercise
    • May experience heavy bleeding that is not your period. In this instance please contact your GP in case antibiotics are needed for infection. If the bleeding persists, please contact the Emergency Room at Liverpool Women’s Hospital on 0151 702 4140
    • May experience a very smelly discharge which could be infection. Again please contact your GP in case antibiotics are needed.
    • Should get your next period when it’s due although it may be heavier than normal
    • Should continue to take the contraceptive pill as you would normally do
    • May experience slight discomfort which will settle with mild painkillers

    If your treatment has been for abnormal cells you will need a check smear in 6 months. This may be at the hospital smear clinic or with your GP. It is important to attend for this as it will confirm whether your treatment has been successful or not. You will not need a smear if the treatment was for bleeding.

    Having a LLETZ Treatment (Loop Excision)

    You will be offered this if you have:

    •  A moderate or severely abnormal smear
    • Abnormal glandular cells on your smear
    • A biopsy that shows CIN 2 or 3
    • A biopsy that shows abnormal glandular cells
    • Your abnormal cells are not visible on the outside of your cervix

    This can be offered at the first visit. The procedure will be explained, and you will be asked to sign a consent form. A colposcopy examination will then be carried out as above. Occasionally it may be more appropriate to have the procedure under a general anaesthetic but if this is the case, your clinician will explain everything and arrangements for a future day case admission will be made.

    We advise all women with coils who are due for loop excision to avoid sexual intercourse or use barrier contraception (e.g. condoms) for 7 days prior to treatment just in case the coil needs to be removed (FFPRHC 2006) Please see section later.

    What actually happens?

    A fast-acting local anaesthetic will be given into your cervix. Whilst it is taking effect the rest of the equipment will be set up: a sticky pad is attached to your thigh to ensure a safe return path for the electric current being used to avoid injury and a plastic tube attached to the top of the speculum to circulate cool air.

    Some of the anaesthetic can sometimes make you feel a little strange: it can make you heart beat faster and your legs feel wobbly. If this happens please do not panic, it is quite normal and will settle quite quickly. Breathe normally and don’t worry about shaky legs.

    Once we are sure that the anaesthetic is working, a thin electrical wire loop is used to remove the abnormal area – hence the name. The area is then sealed to stop it bleeding with another type of electrical instrument. It is a very safe procedure and takes about 15 minutes.

    What if I have a coil (intra-uterine contraceptive device, IUS, IUCD)?

    You will be offered the choice of having the coil removed or leaving it in. Both options have associated problems.

    If the coil is left in the strings may get cut by the loop. This will not have any immediate effects but may cause difficulty when the coil needs to be removed.

    Taking the coil out can only be done if there is no chance of you getting pregnant. Hence you will be asked whether you have had sex in the last 7 days. If there is any doubt or concern, the treatment will be delayed until the coil can be safely removed. If it is taken out, it can be replaced 6 weeks later but this is not done in the hospital.

    We advise all women with coils who are due for loop excision to avoid sexual intercourse or use barrier contraception (e.g. condoms) for 7 days prior to treatment just in case the coil needs to be removed (FFPRHC 2006).

    Is the treatment painful?

    It is usually painless or minimally uncomfortable because of the local anaesthetic used. Some women experience period type pains for a day or two, but this will settle with usual over the counter painkillers.

    Does the treatment have any side effects?

    LLETZ treatment is generally very safe but as with all surgery there can be complications:

    •  Up to 50% of women will experience 10 days of bleeding and discharge which may be moderate to heavy
    • Many experience pain for a day or two afterwards
    • Bleeding is more likely if you get an infection in the raw area on your cervix which takes about 4 weeks to heal
    • If you do get an infection there will be a smelly discharge or increased bleeding. In this case contact your GP for antibiotics
    • In very rare cases the bleeding is severe, and the woman needs to be admitted to hospital.
    • Bleeding can occur 2 weeks after the procedure as a result of bacteria living in the vagina causing the blood vessels to open up.
    • Some women notice a difference in the timing and length of their periods afterwards
    • There is a small chance that as the cervix heals it scars up making the canal narrow and makes it difficult for the blood to escape when you have a period. This is called stenosis.
    • Research suggests that with a loop of less than 10mm deep there is no associated increase in the chance of pre-term labour or pre-term rupture of the membranes. There may be a small increase in miscarriage before 20 weeks, but this is small and controversial. Deeper and repeat treatments could increase your chance of premature delivery.
    • We aim the treatment to remove all the abnormal cells but occasionally some get left behind (residual abnormality). This is why it is important to attend for your follow up smear which will recognize if any abnormal cells and HPV virus are still present.
    • Damage to other tissues is very rare
    • Loop excision does not affect how easy or otherwise it is for you to get pregnant

    Please note that some travel insurance companies will not provide you with health insurance following this procedure. You may wish to rearrange your colposcopy treatment appointment if you are going on holiday or flying within four weeks of the treatment date.

    To keep the risk of infection as low as possible you MUST AVOID:

    • Sexual intercourse for 6 weeks
    • Using tampons for 6 weeks
    • Swimming for 6 weeks
    • Taking long soaks in the bath for 2 weeks (shower instead)
    • Undertake excessive exercise for 2 weeks

    If you have any problems relating to a treatment you can speak to a nurse colposcopist by telephoning:

    0151 702 4266 – Crown Street Site

    0151 529 3378

    (These lines are ONLY for post treatment issues)

    Can I bring someone with me?

    Yes of course. It is easier to have someone to take you home afterwards although you are safe to drive. You should take it easy for the rest of the day.

    What about work?

    You can go back to work the day after as long as it does not involve lifting or strenuous activity. If so, you may need to take a few days off.

    What if I am due to go on holiday?

    We recommend waiting until after a holiday to have treatment because of the restriction with swimming and sex as outlined above. We can re-book you to have your treatment at a later date. Please do not worry that this will cause you problem to get worse: it won’t. If you are pregnant we wait until you are 3 months post-delivery before performing treatment.

    Please note that some travel insurance companies will not provide you with health insurance following this procedure. You may wish to rearrange your colposcopy treatment appointment if you are going on holiday or flying within four weeks of the treatment date.

    What happens next?

    The removed tissue is sent to the lab and we write to you with the results usually within 6 weeks. We do not give results over the telephone. Sometimes more treatment is needed so we will ask you to return to the clinic to talk through your choices.

    You will be asked to have a smear 6 months post treatment to ensure that there are no abnormal cells or HPV virus left behind. This may be done in the hospital clinic or at your GP surgery. For 95% of women this will be all that is needed.

    For a few women the problem returns, and you have to have a second treatment. For about 3 in every 10,000 treated women, cancer can still develop and that is why it is so important to have follow up cervical screening tests.

    Very rarely women may need to have a hysterectomy, but this will all be discussed when and if necessary.

  • Having a Cervical Biopsy

    The leaflet is detailed below, or you can download the 'Having a Cervical Biopsy' leaflet in PDF. 

    A biopsy is a tiny pinch of skin cells taken from the cervix and sent to the pathology lab to find out if there are any abnormal cells present. If they are present the lab will be able to grade them so a plan for treatment can be made if necessary. Usually more than one biopsy is needed and they will be taken at your appointment, you don’t usually have to make a return visit to have them done. Any bleeding will be stopped at the time by applying a special paste or using a silver nitrate stick.

    Biopsies have no harmful effects but you are advised:

    • To avoid sexual intercourse for 2-4 days
    • Avoid Using tampons for 2-4 days
    • Avoid Soaking for a long time in the bath for 2-4 days
    • Avoid Excessive exercise for 2-4 days
    • You may have a moderate blood loss for up to 6 days
    • 1 in 20 women experience pain which may last for 2 days and may require paracetamol to settle

    You will be informed of the results by letter within 6 weeks

    What might the biopsy show?

    • No abnormal cells
    • Inflammation or HPV – this is regarded as a normal finding
    • CIN stands for Cervical Intra-epithelial Neoplasia and is the medical term used to describe cell changes in the cervix that have been confirmed by biopsy. They are graded on a scale of 1 to 3. THEY ARE NOT CANCEROUS
    • CIN 1 – this means 1/3 of the cells in the affected area are abnormal. They may be left to return to normal or you may be offered treatment if they are still abnormal after 2 years.
    • CIN 2 – this means 2/3 of the cells are abnormal and treatment is usually offered to return these cells to normal
    • CIN 3 – this means all the cells in the area are abnormal. Treatment will be needed to return these cells to normal.
    • Only vary rarely will a biopsy show cell changes that have already developed into cancer
  • Having A Coagulation Treatment

    The leaflet is detailed below, or you can download the 'Having A Coagulation Treatment' leaflet in PDF. 

    This will be offered to you if:

    • You have CIN 1 changes on your cervix that have not resolved over the past 24 months
    • You have an ectopy that is causing troublesome bleeding with sexual intercourse and you have had biopsies that have confirmed no major abnormality.

    Hence this treatment will never be offered on a first visit.

    The procedure will be explained and you will be asked to sign a consent form.

    You will then undergo a colposcopy so the clinician can see clearly where the area of concern is. Sometimes we use iodine to show up the area.

    A fast acting local anaesthetic can be used if you have a large area although most smaller areas can be treated without. A heated probe is applied to the cervix for 20 seconds at a time until the whole area has been treated. You will then be allowed to get dressed again.

    You should be fine to drive home if needed and do not need to take time off work.

    After treatment you:

    • Will get a blood stained sometimes black discharge for up to 4 weeks. During this time you MUST NOT:
      • have sex
      • use tampons
      • go swimming
      • undertake excessive exercise
    • May experience heavy bleeding that is not your period. In this instance please contact your GP in case antibiotics are needed for infection. If the bleeding persists, please contact the Emergency Room at Liverpool Women’s Hospital on 0151 702 4140
    • May experience a very smelly discharge which could be infection. Again please contact your GP in case antibiotics are needed.
    • Should get your next period when it’s due although it may be heavier than normal
    • Should continue to take the contraceptive pill as you would normally do
    • May experience slight discomfort which will settle with mild painkillers

     

    If your treatment has been for abnormal cells you will need a check smear in 6 months. This may be at the hospital smear clinic or with your GP. It is important to attend for this as it will confirm whether your treatment has been successful or not. You will not need a smear if the treatment was for bleeding.

  • Management of your Miscarriage

    The leaflet is detailed below, or you can download 'Management of your Miscarriage' leaflet in PDF. 

    What is this leaflet about?

    We would like to offer our sincere condolences for your pregnancy loss. This leaflet contains information about how we manage your miscarriage here at the Liverpool Women’s. We understand that this is can be an extremely distressing time and we are here to support you.

    Every miscarriage is different and how we manage it is based on your thoughts and wishes. Although this leaflet is about the management of miscarriage there are also leaflets available on the support available for you and your family at this difficult time.

    If after reading this leaflet you have questions or queries please contact us at the Gynaecology Emergency Department (GED) 0151 207 4438.

    What are the options available to me?

    There are three broad options for management of miscarriage and in most cases there is no one “right” answer.  It may be that you, or someone you know, have experienced this before and you may already know what you want to do. However if not we hope this leaflet will help you understand your options.

    The 3 options are:

    • Conservative management
    • Medical management
    • Surgical management

    In all 3 options it is reassuring to know that:

    • The risk of infection or harm are very small with all 3 methods
    • Your chance of a healthy pregnancy next time are the same with all 3 methods
    • Women cope better when given clear information, good support and a choice of management options

    Natural management (also known as conservative or expectant management)

    What happens?

    In this option we allow time for your body to complete the miscarriage itself. This can take days or weeks and the amount of bleeding or pain that you experience is difficult to predict. The further on in pregnancy you are may mean that you have heavier bleeding or stronger cramps but this is not always the case.

    You will be provided with painkillers to help with the period cramps that can be associated with miscarriage.

    A follow up scan in the Early Pregnancy Assessment Unit (EPAU) will be booked for you for two weeks after your miscarriage is diagnosed.  This way we can advise you whether your miscarriage is complete.  If the miscarriage has not completed we can advise you on your next options.

    There is a chance you will experience heavy bleeding you should contact the Gynaecology Emergency Department (GED) on 0151 207 4438 if you are worried about the bleeding. The general advice is to contact us if your bleeding is so heavy that you need to change pads every half hour or if you are feeling unwell, such as feeling dizzy or faint.

    We are here for you throughout your natural management should you wish to contact us sooner for advice or if you wish to discuss alternative management.

    What are the risks?

    • Infection can occur in about 1 in 100 women. Signs to look out for are
    • Raised temperature or flu-like illness
    • Vaginal loss that changes colour to be darker or smells bad
    • Pain that gets worse rather than better
    • Bleeding that gets heavier rather than lighter

    If you develop any of these symptoms please contact us at the Gynaecology Emergency Department.  We will need to assess you and you may need antibiotics.

    • About 1 - 2 in 100 women will have heavy bleeding bad enough to require blood transfusion. Some of these women need to undergo emergency surgery to stop the bleeding and complete the miscarriage.  This is why we ask you to contact us should the bleeding become heavy or you feel unwell.
    • Sometimes during a natural miscarriage, pregnancy tissue does not completely pass even within two to three weeks. This is why we see you for a follow up scan so we can advise on further management options for you.

    What are the benefits?

    The main benefit is that you are in control of your miscarriage and can avoid intervention. Some women feel that this helps them deal with the miscarriage better however this is not how everybody feels. Natural management can be successful in up to 9 out of 10 women therefore avoiding any medical intervention.

    What are the disadvantages?

    There is an element of waiting for things to happen and some women find this difficult. Some women do not want to be at home during their miscarriage because they don’t want to worry about getting into hospital if they have heavy bleeding or if they have other children at home who they do not want to be around while miscarrying.

    Although over 9 out of 10 women who chose natural management miscarry within 3 weeks it may not happen on its own. This could mean you require medical or surgical management despite waiting for nature to take its course.

    Medical management

    This can be done in one of two ways,

    • With us as an inpatient for a day
    • At home

    Both are safe options and will depend upon your choice. There are certain circumstances when we would advise you to have your management with us. You may already have been made aware of this but if not this will explained when you get the chance to speak to a medical professional face to face before arranging your management of choice.

    Currently medical management at the Liverpool Women’s is made of up two parts. Initially you will receive a medicine called mifepristone that prepares the womb for the miscarriage. 

    If you choose to manage your miscarriage at home you will be given the second part of the medical management to take home with you along with pain killers. We ask you to take this medication 48 hours after your first medication. This medication is called misoprostol and it causes the pregnancy tissue to pass.

    We ask you to contact us at the GED after 24 hours if you have not had any bleeding. This is so we can review you to see if you need a further dose.  If after this second dose there is no bleeding or minimal bleeding after 7 days we will ask you to contact the GED to arrange review.

    If you decide to stay with us in the hospital you will receive the medication, misoprostol and if there is no bleeding after 4 hours a second dose will be offered to you. If after a further 4 hours there is still no bleeding a doctor will review you and discuss a 3rd dose.

    If there is no bleeding after the 3rd dose the doctor will discuss with you the next steps. This would either be going home and awaiting events or surgical management. We encourage giving your body time to allow the miscarriage to happen as usually heavy bleeding will occur in the following few weeks however we appreciate for some women this is not an option they wish to pursue.

    If you do go home to await events and have heavy bleeding we will ask you to perform a pregnancy test in 3 weeks’ time and alert the GED if this is positive. If you have no bleeding at 7 days or you have continuing bleeding or the bleeding is getting heavier please contact the Gynaecology Emergency Department (GED) for further advice.

    You can sometimes pass your pregnancy tissue before the second part of the medical management. If this happens please contact the GED and tell the nurse that you have had bleeding and think you have passed the pregnancy. They may ask you further questions about what you have passed and may invite you in for a review. They may also ask you to bring the pregnancy tissue with you if you still have it. Some women instinctively flush the toilet after passing the pregnancy tissue but some women prefer to remove the remains for a closer look. We will provide you with an appropriate receptacle at the start of your miscarriage management to bring the remains into us if this is what you wish.

    What are the risks?

    • Infection is common affecting about 1 in 10 women
    • Bleeding that lasts up to 2 weeks is common but heavy bleeding is uncommon, about 1 in 1000 women

    Medical management is successful in 80-90% of women however if it is not successful you may require a further dose of the medicines or be offered surgical management.

    What are the benefits?

    The main benefit is avoiding a surgical procedure and the associated general anaesthetic.

    Some women prefer this option as they feel more in control by choosing when the miscarriage will happen.

    As with natural management some women find acknowledging the passing of the pregnancy helps with the grieving process of a miscarriage.

    What are the disadvantages?

    There are side effects to the medication most commonly tummy cramps and diarrhoea. Sometimes these pains and the associated bleeding can be quite distressing.

    If you chose to manage your miscarriage at home some women worry about having to get back to the hospital if they have heavy bleeding.

    Some women have concerns about seeing the baby, particularly if they are more than 10 weeks when the miscarriage occurs.

    Bleeding can last for up to 3 weeks. Sometimes this is due to small amounts of pregnancy tissue remaining and in some cases, it may be necessary to consider surgical management.

    Surgical Management

    This involves a day case operation that is performed under general anaesthetic (i.e. you are asleep). You may have heard it referred to as a D&C which means dilatation and curettage. Although this is technically a procedure done for heavy periods some people use this term to explain surgical management of miscarriage also. The term evacuation of retained products of conception (ERPC) may also be used.

    What happens?

    The cervix (the neck of the womb) is gently dilated (stretched) and a narrow suction tube is inserted into the uterus to remove the pregnancy tissue. The operation only last about 5-10 minutes however you could expect to be in the theatre department for over an hour due to the time taken for the anaesthesia and recover afterwards. The pregnancy tissue is sent to the pathology for examination to ensure it is normal pregnancy tissue. This examination will not provide an answer for why your pregnancy miscarried.  For more information on this please see the section below on how my pregnancy is cared for after I have passed and our Histology patient information leaflet.

    After the procedure you should be able to go home the same day. You may have some period pains afterwards. You may bleed for up to 2-3 weeks which may stop and start but should gradually tail off.  If it ever gets heavier than a period or you are concerned please contact the GED.

    At the Liverpool Women’s we perform surgical management on Monday afternoons and Fridays mornings.  You will be asked to attend the Gynaecology Unit on the second floor where you will be shown to a private room. You can have a relative or friend with you for support while you await your procedure. You will be seen by the anaesthetist and surgeon who will be caring for you before you go to theatre.

    What are the risks?

    • In 1 in 20 women some of the pregnancy tissue can remain in the womb after the procedure. This may require a second operation or a dose of the medical management to complete the miscarriage
    • About 1 in 30 women can develop an infection
    • Bleeding that lasts for up to 2 weeks is common but heavy bleeding is uncommon, less than 1 in 500. It is rare that a woman would require a blood transfusion
    • Scarring to the inside of the womb can occur rarely, less than 1 in 100 women. The clinical significance of this scarring is unknown
    • Injury to the cervix or rarely – in less than 1 in 200 women the womb can be perforated (a hole made). If this happens there can be injury to the bowel, bladder or blood vessels inside your tummy.  If there is a concern that this has happened the surgeon may perform a laparoscopy (key hole surgery) to look inside the tummy and if necessary they may need to perform a laparotomy (cut on the tummy) to repair any injury.  This is extremely rare.  In most cases if there is a small perforation it will heal itself with some antibiotics to prevent infection and should not affect future pregnancies
    • Very rarely the general anaesthetic can cause a severe allergic reaction, about 1 in 10,000 or even death, 1 in 100,000

    What are the benefits?

    Some women prefer this method of management as they know when the miscarriage will happen and they can plan around it. Some women also prefer that the miscarriage happens while they are asleep.

    What are the disadvantages?

    Some women are frightened of going to theatre or staying in hospital. The anaesthetic may make you feel groggy afterward for a day or so.

    What happens after your miscarriage?

    How is my pregnancy cared for once I have passed it?

    All pregnancy losses are transferred to the care of the honeysuckle bereavement team.

    If an embryo/ tiny baby is identified visually by staff caring for you it will not be necessary for any examination to take place. With your signed consent The Honeysuckle Team will then arrange for a communal cremation to take place at a local crematorium. If you wish to discuss making your own arrangements please contact The Honeysuckle Team.

    If you miscarry at home or outside of the hospital setting you are most likely to pass your pregnancy loss into the toilet.

    You may want to retrieve your pregnancy loss to have a closer look or flush the toilet (many people do this automatically). There is no right or wrong answer. It is important you do what you feel is best for you.

    If an embryo/ tiny baby is not identified by staff caring for you histopathological testing will be requested by medical staff. For more information please see enclosed patient information leaflet Histology patient information leaflet.

    What does miscarriage mean for future pregnancies?

    Because miscarriage is sadly a common occurrence in early pregnancy, 1 in 4 early pregnancies is believed to miscarry, it is unlikely that there is any significant medical cause for you miscarriage that would increase your chances of it happening in your next pregnancy. It is highly likely that your next pregnancy will not end in miscarriage.  We do however; investigate women who have had 3 miscarriages in a row through our recurrent miscarriage clinic.  If this is something you have experienced please ask about referral to this service.

    There are no rules about when you can start trying for a baby again and every couple has different feelings about this. It is best to wait for your next period as it helps us to date the next pregnancy but there would be no harm if you got pregnant before then.

    In order to ensure we can offer early pregnancy scans in our EPAU to women who have bleeding or pain in early pregnancy as soon as possible we cannot provide a reassurance scan for women who have suffered a miscarriage unless they have suffered two miscarriages in the last two pregnancies. We do offer a private service for early pregnancy reassurance scans when you are over 6 weeks that can be booked via the imaging department. Please contact them at 0151 702 4483

    This leaflet has been produced from the Miscarriage Association ‘Management of miscarriage: your options’ leaflet 2016

    Useful resources

    Gynaecology Emergency Department

    GED telephone: 0151 207 4438

    Honeysuckle Team

    Telephone number: 0151 702 4151 (Monday to Friday, 8am to 4pm)

    Website: www.liverpoolwomens.nhs.uk/patients/honeysuckle-bereavement-service/

    Email: honeysuckle@lwh.nhs.uk

    Miscarriage Association

    Telephone: 01924200799

    Website: www.miscarraigeassociation.or.uk

    Email: info@miscarriageassociation

  • High Dependency Unit (HDU) Pre-operative Information

    The leaflet is detailed below, or you can download the 'High Dependency Unit (HDU) Pre-operative Information' leaflet in PDF.

    What is HDU?

    HDU is a 2-bedded unit located on Gynaecology unit on the 2nd floor. This unit looks after patients immediately after surgery when they are in need of continuous, specialist care which is not available on a general ward.

    Most of the patients in HDU are transferred to a general ward within 24 / 48 hours.

    In some rare cases, if more specialised care and investigations are required, patients may be transferred to an Intensive Care Unit at another hospital.  A specialist team of doctors and nurses will accompany patients in these circumstances.

    The Medical Staff

    Doctors specialising in anaesthesia and Gynaecology are available for the unit 24 hours a day.

    There is a ward round every morning during which decisions are made regarding your treatment plan and possible transfer to the ward. Your care will be reviewed as necessary during the day and night by the team

    The Nursing Staff

    The nursing and medical staff work closely together to make sure you receive high quality care and treatment.

    A trained HDU nurse who has completed extra critical care training will care for you during your stay. They will be responsible for all your nursing needs.

    Whilst in HDU you will be looked after / by the multidisciplinary team

    Consultant Anaesthetist

    Consultant Gynaecologist

    SHO (Senior House Officer) /SPR (Specialist Registrar) Anaesthetist

    SHO/SPR Gynaecologist

    Twenty four hour HDU trained nursing team

    Specialist Nurses- When required

    Operating Department Practitioner- When required

    Physiotherapy team- when required

    Dietician- when required

    Pharmacy team will review daily

    Radiology team- when required

    Microbiology (infection control) team- when required

    Hospital Chaplaincy- when required

    Equipment

    The equipment and sounds within HDU may make you feel anxious.  This equipment is necessary and all the staff are experienced in its use, and will answer any questions you may have. Some of the equipment we use include:

    Breathing equipment

    Usually oxygen is given to patients through a face mask or nasal specs. However you may need help with your breathing and be attached to a machine that improves breathing. (CPAP) – see separate leaflet.  The nurse will fully explain all care that is given.

    Monitors

    Leads on your chest and drips in your arm, neck or chest will be connected to a Monitor to help us to measure and record your heart rate, blood pressure and fluid balance.

    This allows staff to detect any changes in your condition.

    Drips/Pumps

    Most patients have several drips in their hand or arm on very rare occasion’s this may also be in foot, neck or chest.

    The fluid pumps regulate fluid given to you through these drips whilst you are unable to eat or drink. Prescribed antibiotics and other drugs can also be given through these drips.

    Drains/Catheters

    Drains to allow fluid to drain from your wound are often inserted in theatre. A tube is also inserted into your bladder (catheter) to allow us to monitor your urine output.

    Pain Control

    You may have an epidural, PCA (Patient Controlled Analgesia) and/or a rectus sheath catheter to help control your pain after your operation. The anaesthetist will discuss with you before your operation the type of pain relief most suitable for you. Your nurse will be checking your level of pain, making sure that the pain killing drugs are working.

    Diet

    On rare occasions you may be unable to eat for a few days and it may be necessary to be fed using ‘specialist fluids’ in a tube through your nose into your stomach (nasogastric tube).

    This will provide energy to help you recover from your operation, improve wound healing and help reduce infection.

    Your consultant will discuss this with you if you if they think it may be necessary post-operation.

    Movement

    The leads attached to your chest, oxygen mask, drips, drains etc. may restrict your movement. The nurses will ensure you are moved as carefully and gently as possible.

    Noise

    HDU can be quite noisy. Do not be afraid if alarms sound on the machines. This is quite normal and does not necessarily mean that anything is wrong.

    Lighting/Windows

    HDU is bright during the day. We dim the lights at night to enable you to sleep.

    Patient’s belongings

    A patient’s stay on HDU is usually short. Due to limited space we advise that all belongings are taken home until you are transferred to a ward. We use our gowns to allow for easy access to drips etc. You may want to bring a toilet bag. Following emergency admission a small selection of toiletries can be provided.

    Visiting

    Visiting times are between 13.30 - 14.30 hrs & 18.00 - 19.30 hrs. 

    This is to make sure you have a rest period, You will need lots of rest after your operation.

    We advise limiting visitors to next of kin and close family only, two visitors at the bedside only please.

    Enquiries

    We ask that only one person be chosen to telephone to ask about you on behalf of your family and friends as this limits the amount of time that the nursing staff spends away from the patients.

    Physiotherapy

    A physiotherapist will visit you if needed. They will encourage you with both breathing exercises and limb movements.

    Transfer

    When you are ready to be transferred to the ward your care will be handed over to your Consultant’s medical team and ward nurses.

    Outreach team

    The team offers advice and support when necessary, and follows up all patients who have been in HDU once they have been transferred to the ward.

    We appreciate this may be a stressful time for you. We will do our utmost to ensure your stay on HDU is as comfortable as possible.

    The Liverpool Women’s Hospital is part of the Mersey and Cheshire Critical Care Network. This helps us provide the best and most up to date care available.

    We are proud of our unit and aim to give the very best care possible.

    However, if you have a complaint or suggestion on improving the service, please see the nurse on duty or ask to speak to the HDU.manager

    If you have any questions or concerns or would like to visit the unit before admission please do not hesitate to call us on 0151 708 9988 ext 1023. 

    Please note that Liverpool Women’s NHS Foundation Trust is a smoke free site. Smoking is not allowed inside the hospital building or within the hospital grounds, car parks and gardens.

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