Gynaecology Leaflets

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

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 08.00-4.00 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 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

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

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

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)

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

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

2. 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.

3. 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

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 is 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.

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, Sue Manuel, or Karen Loy on 702 4147 or 702 4319

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 patients 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 patients 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 patients 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 patients 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 patient 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 patients 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 recognise 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 4 weeks
• Using tampons for 4 weeks
• Swimming for 4 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)

Out of hours phone the Gynae Emergency Dept on: 0151 702 4140

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 patients this will be all that is needed.

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

On very rare occasions a hysterectomy may be needed, but this will all be discussed if and when necessary.

 

 

 

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

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 most appropriate way to confirm vulval cancer, 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 sclerosis (please request the “Lichen Sclerosis” 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 4131 to speak to the Rapid Access Clinic Early Diagnosis Support Workers

 

Or speak to the nursing staff in the Gynaecology Emergency Department on 0151 702 4140

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.

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.

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.

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.

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.

Alterations to our clinic during the Covid pandemic

In order to keep everyone safe at present it is not possible for you to bring someone with you to your appointment. Please be assured that we will do everything we can to support you.

You will be required to wear a mask or visor at all times (unless exempt) and to keep a 2m distance in the waiting room and public areas.

Please do NOT attend your appointment if:

• You have symptoms or signs of a Covid infection
• You have had a positive Covid test in the last 10days
• You are currently isolating or in quarantine for any reason

If you cannot attend, please contact the Access Centre on 0151 702 4328 and your appointment will be re-arranged

When you enter the hospital (Crown Street) or department (Aintree) you will be asked about symptoms of Covid and have your temperature taken. We will not be able to proceed with your appointment if any answers / results are not satisfactory.

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 patients 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 females have the virus at some time. In time, most 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. If you have children, we recommend that you try to arrange for someone to care for them 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 cauterisation also called coagulation or thermal ablation. 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 patients 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 patients 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 patients 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 patients 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 patients 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 patient 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 patients 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 recognise 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)

Out of hours phone the Gynae Emergency Dept on: 0151 702 4140

 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 patients this will be all that is needed.

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

On very rare occasions a hysterectomy may be needed, but this will all be discussed if and when necessary.

 

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 patients 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 very rarely will a biopsy show cell changes that have already developed into cancer

 

 

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 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.

 

 

 

 

 

 

 

 

 

 

 

 

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.

The leaflet is detailed below, or you can download 'General Care of the Vulval Skin' leaflet in PDF.

This booklet has been designed to help you care for your vulval skin based on what you will have been prescribed from the clinic. Remember we can only advise: applying your treatments properly is up to you. You should continue soap substitutes and emollients (moisturisers) for life but only use medications as instructed. If you are diagnosed with a specific skin condition make sure you have a leaflet about it.

Washing

• Avoid soaps, bubble baths, shower gels, body scrubs, deodorants, wet wipes, baby wipes, douches and feminine wipes in the vulval area. Even 'simple' products and those advertised especially for the feminine area contain preservatives and chemicals that can irritate your skin. Washing with only water dries the skin and aggravates symptoms.
• Use a soap substitute such as Dermol, or hydramol. There are products available to add to bath water.
• Wash only once a day, over cleaning aggravates symptoms.
• Try and avoid washing your hair as you bath if you can.
• In the shower, wash your body and hair if necessary, first, keeping your legs together to prevent the products reaching your vulval skin. Then rinse the vulva either by taking down the shower head or by using a jug of clean, warm water. Then use your soap substitute and rinse thoroughly.
• Dab dry with a soft towel, don't rub
• Apply emollient.

General Advice

• Wear loose fitting silk or cotton underwear in white or light colours as dark textile dyes (black, navy) may cause an allergy. If you wash new, dark underwear a few times before wearing it, it will be less likely to cause a problem.
• Replace tights with stockings and wear loose fitting trousers or skirts. At home you may find it more comfortable to wear long skirts without underwear.
• Close fitting clothes such as tights, cycling shorts, leggings or tight jeans should be avoided.
• Sleep without underwear.
• Symptoms of burning can be relieved by applying an ice pack or frozen gel pack wrapped in a towel to the skin. Do not apply the pack directly to the skin
• If you have pain, Use a foam rubber doughnut for long periods of sitting and try to stand / walk for a few minutes every so often.
• Learn some relaxation techniques to do during the day.
• If you experience a lot of itching you can buy anti-histamines over the counter to help. Take a non-drowsy one during the day and a drowsy one at night. This will help you to sleep better and scratch less. You can just take these when needed.

Things to Avoid

• Fabric conditioners and biological washing powders. You may want to wash your underwear separately in a non-biological washing powder or gel.
• Over the counter creams including baby or nappy creams, herbal creams such as tea tree oil and aloe Vera and 'thrush' treatments as they may include possible irritants.
• Wearing panty liners or sanitary pads on a regular basis and certainly not perfumed ones.
• Antiseptic as a cream or added to bath water in the vulval area.
• Coloured toilet paper.
• Wearing nail varnish if you tend to scratch your skin.
• Shaving or waxing your pubic hair - trimming is better.
• Vaginal douches.
• Spermicidally lubricated condoms.
• Contraceptive creams and spermicides.
• Swimming in highly chlorinated pools unless a barrier cream is applied first.
• Hot tubs.
• Activities that put direct pressure on the vulva such as cycling and horse riding.
• Exercises that create a lot of friction in the vulval area; try lower intensity exercise such as walking.

Emollients

• It is recommended to moisturise your vulval skin 4-5 times a day as this will protect the skin and prevent flare ups even if you do not have symptoms. Find one that suits you; if the first one you try does not work well; it is always worth trying another one.
• Suitable emollients are: Balneum cream, Hydramol, Balneum plus cream, Epaderm, Diprobase, 50:50 and Aveeno.
• If your skin is irritated, you can keep it in the fridge and dabbed on to cool and soothe the skin as often as you like.
• In our busy lives it is easy to apply moisturiser morning and evening but less easy during the day. Try keeping your cream next to the toilet; firstly you will see it and remember to use it every time you go, secondly, you will already be half undressed and it will be easy to apply.
• Barrier creams such as Epaderm or Hydramol can be applied prior to passing urine to protect your skin and prevent the urine stinging. It can be smeared on the edges of your sanitary or incontinence pad if it’s easier and should be used prior to swimming.
• Decant some into a smaller pot to carry in your handbag. This means you will never be without relief wherever you are. Travel pots can be bought from Boots, Superdrug and sometimes Primark very cheaply.
• Continue with the soap substitutes and moisturising even when your symptoms have settled as this is what helps keep the condition under control. It is particularly important to continue after a course of steroid ointment. Ensure that your GP has your soap substitute and emollient on a repeat prescription basis so that you can get it more easily. Most symptoms reoccur when you stop using the treatments regularly.
• Remember, we can only advise treatment. Applying and maintaining it to control your symptoms is down to you so make sure you know how to manage your condition especially for when you get discharged.

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

If you are attending hospital on an outpatient basis you may have questions, such as where to report on arrival and what will happen during your visits.

The aim of this information is to welcome you and explain briefly what to expect during your visits.

How to find us

The Outpatient Department is on the ground floor of the hospital. It is signposted and also shown on maps located around the hospital. Please ask at the Main Reception if you are unsure and the receptionist will direct you. Once there, you should report to the reception desk at the main Gynaecology waiting area, where the staff will check your personal details, e.g. full name, date of birth, GP details etc and you will be asked to take a seat in the waiting area.

Will I be able to bring someone with me?

Yes. You are welcome to bring either a friend or relative with you. If you are attending the clinic for infertility reasons, please bring your partner with you.

If I arrive earlier than the time of my appointment will I be seen earlier?

A number of clinics run alongside each other. We ensure patients are seen at the relevant clinic, in appointment time order. You should plan your journey so that you arrive just before your appointment time, arriving earlier will not result in you being seen earlier. Sometimes there are delays in clinic due to unforeseen circumstances, if this happens the staff will keep you informed of the clinics in progress.

I need to cancel my appointment, what shall I do?

If for any reason, you are not able to keep your appointment, please tell us as soon as possible so that we can rearrange your appointment. We can then give an appointment to another patient. Please call Patient Services Department on their direct line: 0151 702 4080 between 8:30 am and 4:30 pm. An answer machine is available out of hours.

What will happen to me when I see the doctor/nurse?

The doctor/nurse will ask you questions about your medical history and any medicines that you might be taking. Some patients may be asked to change into a gown for a physical examination or treatment. You will be under the care of a consultant, who is in charge of your care. You will see the consultant or a member of his/her team. It may not be possible to see the same doctor at each visit. If you wish to see a particular doctor please ask a member of staff, and every effort will be made to accommodate this.

Will anything else happen to me whilst I am at the clinic?

You may need to have a blood test or other minor treatment/investigation carried out whilst you are at the clinic. The reasons for these will be explained by the doctor.

What if I don’t understand about my treatment?

Your visit to the clinic is a good time to discuss things with your doctor. It can be difficult to remember all the questions you want to ask. You may find it helpful to write down any questions you want to ask. Please ask the doctor or nurse if you do not understand what has been said. Patient Information leaflets are readily available within the department, if you require a leaflet but are not offered one, please inform the nurse before you leave clinic.

Will I have to be seen by student doctors or other students?

This hospital is involved in teaching students and in research work. Student doctors and other clinical staff in training are sometimes present in clinic. You may be asked to discuss your condition with students and allow them to examine you. You may also be asked to take part in research, if you do not wish to participate, please tell a member of staff. You do have the right to decline and this will not affect the care you receive.

Will I be able to bring my children with me when I attend?

Although I appreciate that it is not always possible to attend the clinic without bringing your children, it is important to point out that we do not have child care facilities available. 

If the doctor prescribes tablets or other medicine will I have to pay for my prescription?

You may be prescribed tablets or other medicine as part of your treatment. If you are not exempt from paying prescription charges the hospital pharmacy will make a charge for item prescribed.

Will I be able to get a drink of tea or coffee?

There is a tea bar available in the clinic waiting area which provides tea and coffee and a sandwich bar is available in the main reception area of the hospital.

Do I need to bring anything with me?

Please bring you appointment letter and any medication you are currently taking in the original container so that we can see the strength and dosage.

Is there a public phone available?

There are public phones available in several areas of the hospital. We would request that you switch your phone to silent so as to not interfere with your consultation.

Will I be able to get help with my travel expenses?

If you are in receipt of income support you may be able to claim back your travel expenses (at public transport rates only). Please ask the clinic reception staff for a claim form.

Security

There is a comprehensive security system, including CCTV cameras in operation both within the hospital and the care park. This is designed to protect patients, staff and property.

What if I am not happy with the service you provide?

We are always keen to receive comments and suggestions about the care you have received. If you are unhappy with your level of care please ask to speak to a Senior Manager. Alternatively you may wish to consult the PALS (Patient Advice and Liaison Service) Officer.

PALS

Liverpool Women’s NHS Foundation Trust

Crown Street

Liverpool

L8 7SS

Telephone: 0151 702 4353

Car Parking

There are parking facilities within the hospital grounds for which a fee is charged. During busy clinic times parking is available free of charge in Mulgrave Street. Security is available at Mulgrave Street Car Park Monday – Friday 7:00 am until 6:30 pm. We advise that this car park is not used when security guards are not present. 

How to find us

By train or coach

Lime Street Station and the Main National Coach Station is a short taxi / bus journey away. Full information on bus and train services is available from Mersey Travel Information Line on 0151 236 7676.

Please note 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.

 

The leaflet is detailed below, or you can download the 'Rapid Access Clinic Postmenopausal Bleeding (PMB)' leaflet in PDF.

What is postmenopausal bleeding?

Post-Menopausal Bleeding (PMB) is vaginal bleeding that happens at least 12 months after your periods have stopped.

What causes PMB?

There can be several causes for bleeding after the menopause. It can be due to a thinned vaginal skin (called atrophic vaginitis), cervical or womb polyps, HRT or occasionally abnormalities of the cervix (neck of the womb) or abnormalities within the womb itself. Rarely, bleeding can be due to cancer of the cervix or womb, but this is the case in only about 1 in 10 women who have had some post-menopausal bleeding.

Why am I attending clinic today?

The purpose of this visit is to do some tests to help us to identify what has caused your bleeding.

What tests will you do?

We will arrange an Ultrasound Scan (USS) when you attend your appointment

This scan is similar to those done in pregnancy. The test measures the thickness of the lining of the womb and provide us with pictures of the ovaries and other pelvic structures to assist with a diagnosis

The USS may be taken through your abdominal wall but more commonly we would ask to use a scanner that is placed in the vagina, as this gives us better and more accurate views of the womb and ovaries.

Is this a painful procedure?

The vaginal probe is small (less than the width of two fingers), and most women tell us it is less uncomfortable than having a smear test done. However, there may be a little discomfort when the probe is moved around to ensure all areas are examined.

What other tests will you do?

A sample may  be taken from the lining of the womb (an endometrial biopsy) using a technique like a smear test.

First a speculum is placed into the vagina, then a very thin straw is passed into the womb and a piece of tissue obtained. Experts can study the biopsy and decide if there are any abnormal cells.

What alternatives are there to this procedure?

The test can be done in an ambulatory hysteroscopy clinic whilst you are still awake, with some pain relief if needed, either tablets or Entonox (gas & air), or local injection (see Hysteroscopy leaflet)

In some cases, you may need to have this procedure under general anaesthetic, this would be a day case stay.

Will this test be painful?

The test may cause some period type pain during the procedure, though this only takes a few seconds to perform. For a few hours afterwards some women experience a dull ache which can be relieved by taking some simple pain killers such as paracetamol.

What else do I need to know about the test?

You may experience some bleeding after the test, this usually settles after a few hours and you may need to use a sanitary towel for protection.

What are the benefits of having this test?

The test is a quick and simple means of obtaining the biopsy which will help us to investigate your problem.

This is repeated

What are the risks associated with endometrial biopsy?

Pain – as previously mentioned there may be some mild pain during and for a few hours following the procedure.

Bleeding – you may bleed a little following the procedure, however this is not expected to last beyond a few hours.

Cervical Shock – rarely, some women experience a fall in their blood pressure during the procedure, causing them to feel faint dizzy and unwell. This usually resolves quickly and there is no long term after effects.

Failure to obtain the sample – occasionally, if the cervix is too tight, or the process is too uncomfortable for you, we may be unable to access the uterine cavity and obtain the sample.

What will happen if you are unable to take the sample?

Occasionally it is not possible to do the test in the clinic and then we would arrange a hysteroscopy.

What is a hysteroscopy?

A Hysteroscopy is a procedure, which allows us to look at the lining of the womb through a special telescope like instrument; we could also take a sample or biopsy or remove a polyp during the procedure.

This procedure can usually be completed while you are awake however if necessary, we can arrange  to do it in theatre with a light anaesthetic while you are asleep, this would involve a day case admission and you are usually  able to go home later the same day.

For further information on hysteroscopy please see the “Hysteroscopy” patient information leaflet that the Trust provides.

What if the cells are normal?

If the cells are normal, then we would not need to take any further action.

What if there are abnormal cells or any problem with the ultrasound?

If there are some minor changes to the womb lining identified on the sample, some hormone treatment (progesterone tablets or a Mirena coil) may be all that is required. If this is the case, further visits to the hospital and regular repeat checks on the lining of the womb will be arranged.

Rarely, cancerous, or pre-cancerous cells are identified within the womb. If this were the case, we would normally advise that a hysterectomy would be necessary to remove the abnormality and aim to cure the problem.

What if I am taking HRT?

We may advise that you consider reducing or stopping your treatment, but we will discuss this with you in more detail in clinic.

What if I continue to bleed after my investigation?

If you have any further heavy bleeding or bleed again 6 months after these investigations, you will need to see your GP for referral you back to the hospital for further investigation.

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

This information sheet may be available in different formats. It is a brief outline of this problem and is not intended to replace verbal communication with medical or nursing staff.

NB: Before considering sterilisation, both you and your partner should be absolutely certain you do not want any more children as this is a permanent method of contraception and reversal is not available on the NHS.

What is Female Sterilisation?

Surgical female sterilisation is permanent contraception for women who do not want more children. Usually this procedure is carried out through the laparoscope, typically as a day case. The surgical objective is to block, or on occasion remove, the fallopian tubes, that carry the sperm to the egg.   

On rare occasion, the procedure may have to be carried out/completed by open surgery which would mean staying in for longer as inpatient and not day case.

What is a laparoscopy?

It is a procedure by which an instrument called a laparoscope is passed into the abdomen to enable to doctor to look inside. It is performed under general anaesthetic. Two tiny cuts, measuring about one centimetre each, are made just below the belly button and by the bikini line. A needle is inserted through the cut to put carbon dioxide gas into the abdomen to swell out the abdominal cavity. This separates the bowel from the abdominal wall so that the laparoscope can be inserted safely. The laparoscope has a powerful light attached with allows the doctor to look inside the abdomen and visualise the fallopian tubes.  The whole procedure takes about 15 to 30 minutes.

If the operation cannot be performed through the laparoscopy a mini laparotomy (small cut in the abdomen above the pubic hair line) would be required to reach the fallopian tubes.

What are the risks involved?

As with all operations there are always some possible risks; please remember they occur rarely. Some will occur during the operation and others may not happen until you have gone home.

There is a risk of the womb being punctured. The risk of injuries to the bowel, bladder or blood vessels is uncommon. These risks are serious but infrequent.  In these circumstances an immediate operation may be necessary to repair the damage, however, this is uncommon. This will involve a bigger wound to the abdomen and you will have to stay longer in hospital. We may advise prophylactic anticoagulation treatment to reduce risk of blood clots.

There is a small risk of bowel injury only being apparent after discharge from the hospital. If you develop increasing pain, abdominal distension, fever or worsening nausea and vomiting within the week following the operation, it could mean that there is a problem following surgery. If this happens, we would ask you to come back to the hospital for review. If you have any concerns about the risks mentioned here, please speak to your doctor.

It is possible that a wound infection may develop after discharge. Any inflammation or discharge at the wound site should be reported to your GP.

Risk of failure

The lifetime failure rate for laparoscopic tubal occlusion with clips is up to 2 – 5 in 1000 procedures at 10 years (uncommon)1, which is much better than the pill, a standard coil or condoms. In the 1st year after tubal sterilisation, the estimated failure rate is 0.1-0.8%.

Will I need to continue with contraception after surgery?

It is advisable to continue with your current contraception until your next period, this includes finishing your current pill packet. If you were using a contraceptive device that was removed during or immediately after the procedure it would be advisable to use temporary alternative contraception (e.g. condoms) until the following period. Different contraceptive methods work in different ways so having some overlap until your next period minimises the risk of a pregnancy.

What alternatives do I have?

There are many other methods of contraception available, which do not require surgery. Please discuss this with your GP or Contraception and Sexual Health Clinic.

For details of your local Contraception and Sexual Health Clinic, please ask a member of nursing staff or visit: www.fpa.org.uk

Alternatively, your partner may consider methods of contraception available to him, e,g, condoms or a vasectomy, which involves surgery as a day case. This too can be discussed with your GP, or Contraception and Sexual Health Clinic.

Information leaflets detailing contraception methods are available on request from a member of staff.

Will I still have periods?

Yes, you will continue to have periods until such time as you start the menopause naturally you will continue to have periods. Women who have been on the pill prior to the surgery may find their periods slightly heavier.

When can I have sex again?

Whenever you feel comfortable to resume normal sexual activity. Remember to use contraception until your next period.

Will I have pain following the sterilisation procedure?

You may experience abdominal bloating with pain. This is due to insertion of gas at the time of the procedure.  Sometimes the pain will be felt in your shoulders and neck. This is not serious and should east off within 12 hours. Simple painkillers can control the discomfort.

What happens when I go home?

• What happens to the stitches?

Dissolving stitches are put into the tiny cuts.  These are usually absorbed and the remnants drop out.  This process can take a couple or so weeks. Keep the wound clean by having daily baths and dry the area thoroughly. If you find the stitches irritating they can be taken out at your GPs surgery.

• How long will it take me to recover?

You will probably need 2-3 days to recover from the procedure and the anaesthetic. Most people will need a few days off work but you can return to work as soon as you feel able.

• Will I be able to drive?

Please arrange to be collected from the hospital when you are ready to be discharged. It is a legal requirement that you do not drive for 24 hours after an anaesthetic. Following this you are able to drive once you have move about freely.

Retained Tissue

Routine laparoscopic tubal sterilisation procedure does not normally involve retaining any tissue. In case of removal of the tubes or tissue obtained for other reason at the time of your operation, this would be sent for examination and you would be informed if this has occurred and of any results. Following investigation the tissue will be disposed of in accordance with health and safety. Only with your prior permission, would tissue be used for research or teaching purposes as part of an ethically approved study.

Is there anything else I should know?

It is very important that you consider your actions carefully before agreeing to sterilisation as it is a permanent procedure and reversal is not always possible and carries a low success rate. Reversal will have to be self-funded privately.

Significant risks:

1. Failure resulting in unplanned pregnancy: the lifetime failure rate for laparoscopic tubal occlusion with clips is up to 2–5 in 1000 procedures at 10 years (uncommon).
2. Sterilisation failure may result in a greater risk of an ectopic pregnancy.
3. Visceral or blood vessel injury at the time of laparoscopy (2 in 1000; uncommon).
4. Death as a result of the procedure (1 in 12 000; very rare).
5. Regret, leading to a request for reversal of female sterilisation, which is usually unavailable on the National Health Service. Regret is common, especially if sterilisation was is undertaken below 30 years of age, if the woman is childless, or if there is conflict between the woman and her partner. Regret is also more common when sterilisation is undertaken at the time of an abortion.
6. Failure to complete the procedure. (This is a recognised risk but there is no robust data to quantify the risk).
7. Other possible risks:

Changes in menstruation may occur following discontinuation of reversible hormonal contraception, especially with the combined oral contraceptive or levonorgestrel-releasing intrauterine system (LNGIUS) such as Mirena IUS or Levosert system. Female sterilisation itself does not adversely affect menstrual function.

Infection

DVT/PE especially if laparotomy was necessary

8. Any extra procedures which may become necessary during the procedure. The risk of laparotomy following laparoscopic tubal occlusion is up to 3 in 1000.

Advantages of female sterilisation

• Sterilisation does not interfere with the act of intercourse.
• There is nothing to remember like taking tablets.
• It is extremely unlikely that you will ever get pregnant again.

Disadvantages of female sterilisation

• Difficult to reverse if you change your mind.
• Complications involved related to surgical procedures and anaesthetic.
• Although rare, there is a risk of failure.
• If you do get pregnant, there is a significant risk of an ectopic pregnancy ( a pregnancy which develops outside the womb)
• Following sterilisation, if you think you may be pregnant or have a period that is lighter than normal, or delayed, sudden or unexplained lower abdominal pain or unexpected vaginal bleeding, you must see medical advice.

Don’t forget there is always someone to talk to if you have any concerns following this procedure.  If at any time you need advice contact, Emergency Room at Liverpool Women’s Hospital on 0151 702 4140.

For further information visit:

http://www.2womenshealth.com

References

Guillebaud, J. Contraception. Your questions answered (2009) Elsevier

RCOG Laparoscopic Tubal Occlusion consent advice number 3, October 2004.

Kovacs GT,Krins AJ. Female sterilisation with Filshie clips: what is the risk of failure? A retrospective survey of 30,000 applications. J Fam Plann Reprod Health Care 2001;28:34–5.

Royal College of Obstetricians and Gynaecologists:  Female Sterilisation Consent Advice No. 3; February 2016

Equal Opportunities

The hospital is committed to promoting an environment which provides equal opportunities for all patients, visitors and staff. If you have any special requirements such as dietary needs, interpreter services, disability needs or a preference for a female doctor, do not hesitate to discuss this with a member of staff who will try to help you.

 

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.

The leaflet is detailed below, or you can download the Pelvic Inflammatory Disease Information Leaflet leaflet in PDF

What is Pelvic Inflammatory Disease?

Pelvic Inflammatory Disease (PID) is a condition that involves infection and inflammation of the upper female genital tract, including the womb (uterus), fallopian tubes and ovaries. Any or all of these parts may be affected, PID is usually caused by an infection in the vagina and the neck of the womb (cervix) passing to the internal reproductive organs.

As the infection develops within the pelvis and becomes more widespread, PID may be diagnosed. If the infection remains untreated, the inflammation can eventually spread to the fallopian tubes. This can sometimes cause abscesses (pockets of infected fluid) to develop. The infection can then spread through the tubes and may also start to affect to other organs such as the bladder and bowel.

About 1 in 50 women a year develop PID. It most commonly develops in sexually active women who are between 15 – 24 years of age. However, this figure may be an underestimate because many women with PID experience few or no symptoms. 

What causes it?

PID can be caused by many types of bacterial infection, but the majority of cases occur as a result of a sexually transmitted infection (STI), most commonly Chlamydia or Gonorrhoea. Sometimes, the infection that leads to PID may start as a result of bacteria introduced into the vagina or upper genital tract during childbirth, an abortion or miscarriage, or a procedure that involves passing a catheter or a surgical instrument into the womb, for example: to take a sample of tissue from the inside of the womb for laboratory testing (endometrial biopsy).

In rare cases, PID can develop as a result of appendicitis, treatment following an abnormal cervical smear, or after the fitting of an IUD (intrauterine device).

What are the symptoms?

The symptoms of Pelvic Inflammatory Disease (PID) are not always very specific, meaning that the condition can be difficult to diagnose. Symptoms may appear suddenly, they may come and go or they may be constant: 

• Smelly or unusual vaginal discharge
• Bleeding between periods
• Fever and vomiting
• Pain deep inside during or after sex
• Ache or pain in the lower abdomen or back 

You may have PID without being aware of it. Sometimes, there are no symptoms at all, if there are, they may not be obvious – for example, you may only experience mild discomfort. 

Are there risk factors?

Having multiple sexual partners is one of the main risk factors for developing PID. The more partners you have penetrative sex with, the more likely you are to be exposed to the bacteria that can cause PID, particularly if you are not using barrier contraception (condoms).

How is it diagnosed?

There is no single test available for diagnosing PID. PID is diagnosed by the symptoms and by a gynaecological examination. This will usually involve a specimen being taken from inside the vagina and cervix, using a cotton wool swab. The examination may cause some discomfort, especially if you do have PID.

• a positive swab result confirms that you do have an infection
• a negative swab result, however, does not mean you are definitely clear of infection. 

Sometimes an additional swab may be taken from the urethra (the tube through which urine empties out of your bladder). This can make it easier to detect chlamydia and gonorrhoea or other infections.

Because PID is difficult to diagnose by the symptoms alone, you may also have a blood test, or an ultrasound scan. 

In some cases, a laparoscopy may be used to diagnose PID. A laparoscopy is a minor surgical procedure where tiny cuts are made in the abdomen. A thin telescope is inserted so that the internal organs can be seen and if necessary, take tissue samples or drain a pelvic abscess (request ‘Laparoscopy’ leaflet for more information).

What is the treatment?

If diagnosed at an early stage, pelvic inflammatory disease (PID) can be treated quickly and efficiently. However, if left untreated, it can lead to more serious, long-term complications (see the ‘Complications’ section). Treatment involves: 

Antibiotics:

A combination of at least two antibiotics is usually prescribed to treat PID. This is because PID often involves several different types of bacteria. Quick and efficient treatment of PID is essential for minimising the risk of fertility problems. 

Antibiotics that are commonly prescribed to treat PID include Ofloxacin, Metronidazole and Doxycycline. You will usually have to take the antibiotics for 14 days. It is very important that you complete the entire course of antibiotics; otherwise the treatment may not be effective. Your partner may also need to be tested and treated with antibiotics.

You should rest until your symptoms improve. If they get worse, or do not get better within 48 to 72 hours of treatment, you should see your doctor again.

In particularly severe cases of PID, you may have to be admitted to hospital where you will receive antibiotics intravenously (through a drip in your arm).   

Surgery:

The bacteria that cause PID can leave scar tissue and collections of infected fluid (abscesses) on the lining of your fallopian tubes. This makes it very hard for an egg to pass along it. The longer PID is left untreated, the more likely scarring will occur. Prompt treatment is essential for minimising the risk of damage to thefallopian tubes and other reproductive organs. Studies suggest that even delaying treatment by a few days can increase the risk of impaired fertility. Sometimes, blocked or damaged tubes can be repaired with surgery, such as a laparoscopy, which can help remove the lesions on the lining of the tubes. However, the results are mixed and it can sometimes cause further scarring. 

A more radical form of surgery is a salpingectomy. This involves the removal of one or both of the fallopian tubes to help stop the spread of further infection. This is only to be considered as a last resort, as the removal of both fallopian tubes will mean you will no longer be able to conceive naturally.   

In the most serious cases of PID, it may be necessary to perform surgery through an abdominal incision (laparotomy) to drain abscesses. In this situation a large drain may be inserted into the abscess to allow it to drain. This would then be removed at a later date. 

Avoid sexual intercourse:

While you are receiving treatment for PID, you should avoid having sexual intercourse because it can interrupt the healing process. It is also important that any partners that you have had sexual contact with in the six months before your first symptoms are tested and treated to stop the infection recurring. If you have not had a sexual partner in the last six months, then you should contact your most recent partner.

What if I have an intrauterine contraceptive device (IUD/coil)?

If your symptoms of PID are not improving within a few days of starting treatment and you have an IUD, your doctor may recommend that you have it removed. If you have had sex in the 7 days before it is removed, you will be at risk of pregnancy, and emergency hormonal contraception (the morning-after pill) may be offered.

Are there any long term effects or complications?

Recurrent pelvic inflammatory disease:

Recurrent PID is where a woman develops PID on a recurring basis. The more often a woman gets PID, the more likely she is to get it in the future. The condition can recur if the initial infection is not entirely cured or because a sexual partner has not been tested and treated. If an initial case of PID damages the cervix, this can make it easier for bacteria to move into the reproductive organs in the future, making it more likely that the condition will develop again. 

Abscesses:

Sometimes PID can cause abscesses on the lips to the entrance of the vagina and on the lining of the fallopian tubes. An abscess is a collection of infected fluid. It can sometimes be treated with antibiotics. If an abscess does not respond to antibiotics, you may require surgery. It is important that abscesses are either treated or removed, as an abscess which bursts can be potentially life-threatening.

Ectopic pregnancy:

The word ectopic means ”in the wrong place”. In a normal pregnancy, the fertilised egg implants in the womb lining. An ectopic pregnancy is one which occurs outside the womb. Over 95% of ectopic pregnancies occur in a fallopian tube. If PID develops in the fallopian tubes, it can scar the lining of the tubes making it more difficult for eggs to pass through. If a fertilised egg gets stuck and begins to grow inside the tube, it can cause the tube to burst, which can sometimes lead to severe internal bleeding. Ectopic pregnancy is a potentially fatal condition.

Infertility:

It is estimated that 20% of women become infertile as a result of PID. This means they will be unable to conceive (get pregnant) naturally. PID can make a woman infertile by scarring the fallopian tubes so severely that it makes it virtually impossible for the egg to travel down into the uterus (womb). Delaying treatment for PID can dramatically increase your chances of becoming infertile.

How to prevent it?

The most effective way to prevent Pelvic Inflammatory Disease (PID) is to protect yourself from sexually transmitted infections (STIs). This means using a condom, femidom or cervical cap. It is also important to get regular sexual health check-ups. 

You can get a check-up easily at your local sexual health clinic. you can find your nearest clinic by visiting the Family Planning Association website (www.fpa.org.uk) which allows you to search for your local clinic using your postcode. 

You should also have a sexual health check if you have had sexual contact with someone who you think may have been infected with either an STI or PID.

References

British Association for Sexual Health and HIV (BASHH) published 2011– UK National Guideline for the Management of Pelvic Inflammatory Disease: www.bashh.org/documents/3572.pdf 

Acute pelvic inflammatory disease Patient information leaflet -published by RCOG in November 2016 https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-acute-pid.pdf 

www.womenshealthlondon.org.uk/leaflets/PID

www.fpa.org.uk

This leaflet can be made available in difference formats on request. 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        

Liverpool Women’s NHS Foundation Trust

Crown Street

Liverpool

L8 7SS

Tel: 0151 708 9988

Reference: Uro_2018-124-v1

Issue Date: 11/2019

Review Date: 11/2022                                          © Liverpool Women’s NHS Foundation Trust

 

 

The leaflet is detailed below, or you can download the 'Fact Sheet For Early Medical Abortion' leaflet in PDF.

Early Medical Abortion Commenced at LWH

(Up to 9 Weeks + 6 Days -Tablet Method)

PLEASE READ THIS LEAFLET CAREFULLY AND KEEP IT THROUGHOUT YOUR TREATMENT AS IT CONTAINS IMPORTANT INFORMATION REGARDING YOUR PROCEDURE AND AFTERCARE

POINTS TO BE AWARE OF BEFORE YOU START THE PROCEDURE

It is important before you take the first tablet that you are certain of your decision to proceed with the abortion.

There are known risks to the fetus from this medication and therefore, we must recommend that once you have taken the tablet(s) that you continue with the abortion.

• It is recommended that you do not smoke or drink any alcohol once the procedure has commenced
• Due to the unpredictability of the procedure, we recommend you inform us of any travel plans arranged.
• If you are breastfeeding you may continue during the medical procedure as only small amounts of the drugs, Mifepristone and Misoprostol pass into the breast milk and are therefore not expected to cause adverse effects in the breastfed infant

EARLY MEDICAL ABORTION PROCEDURE

First Part of your Treatment

You are advised to attend the Bedford Centre alone. If necessary- one support person may attend with you, however, you will be seen by the nurse alone. Children are not permitted on the department. You will be given a tablet called Mifepristone to swallow with water whilst in the clinic. If you vomit within 30 minutes of taking it contact the clinic as you will need to return for another tablet.

• Following this tablet you may experience some nausea and / or vomiting also bleeding and period type pain.
• It is important to note that bleeding at this stage does not mean that you have passed the pregnancy therefore you should continue with the next stage of treatment as planned
• If you have discomfort you can take over the counter pain relief such as Paracetamol and Ibuprofen as per package directions

Final part of Treatment at home

• You are advised to have a responsible adult stay with you at home when you take the Misoprostol tablets and to remain with you the rest of the day and overnight.
• You will be given 4 tablets called Misoprostol to be taken at home 48hours after the First medication and they can be taken in the following way

Option 1 - this is preferred method as you will experience fewer side effects.  Place 4 of the Misoprostol tablets into the top of your vagina as high as you can place them. This can be done lying down or squatting. After two hours, repeat this process with the other two Misoprostol tablets.

Or

Option 2 - taken by mouth.  Place 2 tablets on each side of your mouth (4 tablets in total), between cheek and gum and allow the tablets to dissolve for 30 minutes.  If after 30 minutes they have not completely dissolved, swallow what is left with water. After two hours, repeat this process with the other two Misoprostol tablets.

What to expect after the final medication at home -

• You will experience vaginal bleeding which can be heavy with blood clots and this may be accompanied by passage of the pregnancy tissue.
• Period type (cramps) pain usually 1-2 hours after using the tablet. For any pain and discomfort, you experience you can use Paracetamol and Ibuprofen. Please read the patient information leaflet with the packet and take as directed 
• You may experience some nausea, vomiting, dizziness, possible diarrhoea or cold or hot flushes. These are known side effects from these tablets and will not stop the process tablet from working.
• For most people the procedure is likely to be completed within 4-6 hours of taking the Misoprostol, however it may take up to a few days.

We request that you contact the Bedford Centre for advice 7 days after taking the Misoprostol tablets if you have only had a slight blood loss without clots or you have not had any bleeding or you continue to have symptoms of pregnancy.

This may mean that the procedure has been unsuccessful.

KNOWN RISKS OF EARLY MEDICAL ABORTION

• The risk of a failed procedure and continuing pregnancy
• Excessive bleeding (haemorrhage) requiring blood transfusion,
• Retained pregnancy tissue requiring further treatment.
• Infection
• Undiagnosed ectopic pregnancy – this is rare
• Emotional / psychological distress following an abortion -If you are not coping, we would suggest that you contact your GP or Liverpool Bereavement Services on 0151 236 3932 so that counselling or support can be arranged.
• Risk of death is very rare.

We give you this information regarding the risks not to alarm you but we feel you would wish know so that you can make an informed decision. More detailed statistics are in the consent form you will have read and signed before starting the procedure.

FOLLOW UP INFORMATION

You will be given a pregnancy test which you should perform two weeks after you have taken the medication. It is very important that you follow this advice as this will determine whether the abortion has been successful.

Please only use the pregnancy test you are supplied with as they are different to the tests you can buy.

You must contact the Bedford Centre on 0151 708 9988 ext. 4509 if the pregnancy test is positive. We will arrange an appointment for you to be reviewed.

If you do not contact the Bedford Centre, we will assume that you have performed the home pregnancy test on the date requested and that it has shown a negative result

DISCHARGE ADVICE FOLLOWING EARLY MEDICAL ABORTION

1. As already discussed, you are advised to have a responsible adult, with you who is aware of the treatment and remain with you until the following morning.
2. You are advised not to travel long distances, especially by air, until you have performed a negative home pregnancy at 2 weeks post treatment. If you do decide to travel, we strongly recommend you inform your travel insurance provider that you are undergoing a procedure.
3. Bleeding following the procedure is very individual. It can last for up to 3 weeks as a continuation of the procedure, this is not a period. It is not unusual for the bleeding to stop and start during this time. With this bleeding we advise you to use sanitary towels not tampons.
4. You are advised to maintain your normal hygiene routine, however whilst you are bleeding when a showering it is important that you do not apply the jet of water directly to the vagina (douching) as this may increase the risk of infection.
5. You are advised to avoid sexual intercourse until you have a negative pregnancy test Using condoms may help to reduce the risk of infection.
6. You can get pregnant before your next period if adequate contraception is not used.
7. Your next period should occur 4 – 6 weeks following the procedure; however, this can be affected by the method of contraception you are using. The bleeding on this period may be heavier than you are normally used to.
8. It is advisable that you limit any strenuous activity including prolonged sports activities until your bleeding has settled.

If you should develop any of the following, either contact the Gynaecology Emergency Department at the Liverpool Women’s Hospital 0151 0151 702 4140 or contact your local Accident & Emergency Department:

• Heavy and continuous bleeding that soaks through 2 or more pads in an hour for a period of 2 hours.
• Severe repeated or continuous abdominal pains - if not eased with the tablets you have taken for pain relief.
• Violent shivering attacks / chills
• High temperature
• Offensive (smelly) vaginal discharge

If you require any further advice regarding this method of abortion you can contact

The Bedford Centre on 0151-708-9988 extension 4509 between 08.30 and 16.30hrs Monday to Friday.

During the procedure if you require out of hours advice for any of the above list or any other concerns, the Gynaecology Emergency Department is open 24 hours a day on 0151-702-4140.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

What is Laparoscopic Vecchietti?

A Laparoscopic Vecchietti is an operation to create a vagina. It is normally used if vaginal dilation has not been successful or is not possible, and it is done by ‘keyhole’ surgery.

Who is this suitable for?

Vaginal dilation is usually the first line treatment to create a vagina. However, if this is not successful or possible, a laparoscopic Vecchietti may be considered. Conditions where a laparoscopic Vecchietti may be offered include Androgen Insensitivity Syndrome (AIS) and Rokitansky syndrome (MRKH). The best time to have this procedure will depend on your condition and your individual preferences/circumstances, and you will be able to discuss this with your doctor in the clinic. You will also be able to spend time with a Psychologist who can support you with decision making and coping with the procedure and its impact in the future.

What will happen before the operation?

You will discuss all the risks and benefits of the procedure in clinic with your doctor, and you will have the opportunity to ask any questions you may have. You will sign a consent form for the procedure when you are seen in clinic. You should take a copy of the consent form home with you. The consent form will be checked again on the day of surgery. If you have any questions before the day of the procedure, you can contact the gynaecology secretary who will pass a message on to  the clinical team.

After your clinic you will need to have a pre-op appointment, where you will see a nurse who will arrange some blood tests and any other investigations if required. You will then need to come to hospital on the day of the operation. You must not have anything to eat or drink from midnight the night before the procedure. You will be seen by the surgical and anaesthetic teams on the ward before the operation when you will have the opportunity to ask any questions you may have since your last consultation.

What does the surgery involve?

It is carried out in the operating theatre with you asleep under a general anaesthetic. You will have three or four small cuts on your tummy (about 1cm in size). The tummy is filled with gas so that the bowel and other organs are well away from the operating area. An olive-shaped bead will be placed at the vaginal dimple. A thread will pass through the centre of the bead, and each end of the thread will then be placed through the vaginal dimple, into your pelvis and out through your abdominal wall on each side. These threads will then be attached to a traction device which will be strapped onto your abdomen. The gas will be removed at the end of the operation. You will have a catheter (tube) put in your bladder to drain your urine so that you don’t need to go to the toilet. The procedure will take about 60 minutes. You will have some stitches in the cuts on your abdomen.

What will happen after the operation?

After the procedure you will stay on the ward for about one week. Each day the threads will be tightened on the device by the doctor or nurse, to pull the olive bead up, stretching the length of the vaginal canal.  After 7 days, the threads will be cut, the device will be removed from your abdomen, and the olive bead will be pulled out of the vagina. This will be done by the doctor on the ward with you awake. The tube will also be removed from your bladder at the same time.

After the olive bead has been removed, you will need to start vaginal dilation, and you will get help and support with this from the nurse prior to going home.

You will also receive a booklet giving you tips for dilation which will help when you start doing the dilation at home by yourself.

The stitches in your abdomen will dissolve by about 10 days after the operation. The recovery time for this operation is 1 to 2 weeks, so you might need to take some time off school, college, or work. You will be sent an appointment to come back to clinic 6 weeks after the operation.

What are the risks of the procedure?

Although generally the operation is very safe, all operations and anaesthetics carry small risks which your doctor will discuss with you when you sign the consent form. You may have some pain around the scars on your tummy which should be controlled with painkillers. Some people get some pain in their shoulder tip which is caused by the gas that was put into your tummy during the operation. This should settle within a few hours.

Infection of the wound can occur, and if your stitches are red and sore or weepy, you should see your GP as you may need some antibiotics.  The other risks of ‘keyhole’ surgery are bleeding, and damage to the bowel or other abdominal organs. These are very unusual complications. If they happen, the surgeon might need to make a bigger cut to open your tummy to repair the damage or to stop the bleeding. This is called a laparotomy. If there is any damage to the bowel, you might need a colostomy which is where the bowel is brought out into a bag on your tummy, to rest the damaged bowel. This is usually temporary. Thankfully, these complications are extremely rare.

What are the alternatives?

Some women decide not to have surgery to create a vagina and continue with vaginal dilation instead if this is possible. Others decide to wait to have surgery at a later stage when the time is right for them. There are other surgical options for creating a vagina, but these are often more complicated procedures with more associated risks. If you have any questions about this, you can discuss them with your doctor.

For further information you can contact a Nurse Consultant Monday to Friday 09:00 – 17:00 on

0151 708 9988 ext 1053

 

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

Introduction

The full name for Rokitansky syndrome is Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, named after the doctors who first recognised it. Girls/women with Rokitansky syndrome are born without a functioning uterus (womb). Sometimes, there may be one/two small uteruses called uterine remnants/horns which normally just consist of muscle. The vagina may be of normal length, or it may be short or absent. The ovaries are normal, although they are often sitting slightly higher up in the pelvis. The rest of puberty including breast development occurs normally. Girls/women with Rokitansky syndrome are genetically female (46XX karyotype).

In a small number of women, Rokitansky syndrome can affect development of the kidneys or part of the spine (backbone). This is why all women diagnosed with Rokitansky syndrome are advised to also have a scan of the kidneys.

Rokitansky syndrome affects approximately 1 in 4500 to 1 in 5000 girls/women. The cause of Rokitansky syndrome is not yet known. Rokitansky syndrome very rarely runs in families, so female relatives are usually no more likely to be born with the condition compared to anyone else.

How is it diagnosed?

Rokitansky is usually diagnosed when a girl is referred to a Gynaecologist because her periods haven’t started, but the rest of puberty has happened as normal. Several tests must be done to confirm the diagnosis. These include blood tests (including a genetic test), an ultrasound scan of the pelvis, and possibly an examination of the vagina. Occasionally if the ultrasound is inconclusive or if there are any other problems such as pain, then an MRI scan may be required.

What treatments are available?

At the moment, there are no treatments as yet to grow or develop the uterus. For some girls/women, regular sexual intercourse stretches the vagina so that no other treatment is needed. For other girls/women, the vagina must be lengthened to allow sexual intercourse to take place. This can be done either by vaginal dilation or vaginal surgery.

Vaginal dilators

Vaginal dilators are plastic moulds that are inserted in the vagina with some pressure. The dilators are inserted, and pressure applied for up to 20 to 30 minutes a day. Gradually wider dilators are used to both lengthen and widen the vagina. Regular use is important for a good result, and treatment can take 3 months or sometimes longer. These are very effective in making the vagina comfortable for intercourse.

We have 2 Consultant Nurses who are available to help you get started on a dilation programme and offer you advice if you encounter any difficulties. You will be given a booklet with top tips for vaginal dilation, and this will help you when you are dilating on your own at home.

In the long-term, for most women, regular intercourse helps to maintain vaginal length. For women who are not having regular intercourse, it is usually advisable to continue using dilators once or twice a week. Vaginal dilation is safe and normally used in the first instance.

Vaginal surgery

If vaginal dilators do not work, there are several surgical techniques which can be used. The most recommended operation for girls/women with Rokitansky syndrome is the Vecchietti procedure. The Vecchietti Procedure is a laparoscopic (keyhole) operation done under general anaesthetic designed to create a new vagina by applying continuous pressure to the vaginal area using a bead which is pulled upwards to stretch the vagina. It works in a similar way to vaginal dilators, but over a shorter period of time. You will usually spend about a week in Hospital. Women will need to use vaginal dilators for some time after having the procedure to widen the vagina and to maintain the vaginal length. Please see our leaflet on Laparoscopic Vecchietti for more information.

Will I be able to have comfortable sex?

Some women with Rokitansky syndrome can have comfortable sex without needing to dilate the vagina first. Others will need to dilate the vagina first to be able to have full penetrative sexual intercourse in the vagina. Some women dilate the vagina with sex, and others use dilators or have surgery as above. Once the vagina has been lengthened you should be able to have comfortable sex.

Will I be able to have children?

Women with Rokitansky syndrome do not have a uterus (womb) that is able to carry a pregnancy. They can have a baby through surrogacy, where another woman with a uterus (womb) can carry the pregnancy for them. They can have their own eggs fertilised with their partner’s or donor sperm and have the pregnancy implanted into the womb of another woman (surrogate) by the process of in vitro fertilisation (IVF). We have a Fertility Centre at Liverpool Women’s Hospital, and we can refer you to have a discussion with a Fertility Specialist if you want more information.

Surrogacy is not the only route to parenthood and many women prefer to adopt and have done so successfully.

There are several uterine transplant trials on going around the world. This may be a possibility in the future, but at the moment it is not an option for women routinely.

Do I have to have smear tests?

No. As you do not have a cervix, you do not have to have a smear test. You might still get the letter inviting you for a smear, but you can let your GP know that this is not required.

Do I still need protection when having sex?

You do not need contraception, but we do still recommend that you use condoms to prevent sexually transmitted infections.

Psychological support

It can be hard to come to terms with various aspects of Rokitansky syndrome, which may not be easy to talk about with other people. We have a Clinical Health Psychologist who can support you with the impact of living with Rokitansky syndrome and with managing the implications of this condition. They also provide essential support in making decisions about starting dilation therapy and they can also support you through the dilation treatment programme or surgery, alongside the Consultant Nurses. It can also be very helpful to make contact with other women with Rokitansky syndrome. There are also several support groups on the internet which can be very helpful.

Contact details

Consultant Nurse

Telephone: 0151 708 9988 ext 1053

Support group & web sites:

MRKH support group: www.livingmrkh.org.uk

Surrogacy websites:  www.surrogacy.org.uk    www.brilliantbeginnings.co.uk

Adoption and Fostering Academy:  www.corambaaf.org.uk

‘Top Ten Tips for Dilation’:  www.dsdfamilies.org

British Society of Paediatric and Adolescent Gynaecologists dilation leaflet: https://britspag.org/wp-content/uploads/2018/10/Leaflet-Vaginal-dilation.pdf

 

 

 

 

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

What is laparoscopic gonadectomy?

Laparoscopic gonadectomy is an operation to remove the gonads. These are the organs that develop into either ovaries or testes, or even a combination of both. Normally there are two gonads, one on either side. They can be found inside the abdomen or in the groin. This procedure is used when the gonads are inside your abdomen, and it is done by ‘keyhole’ surgery.

Why would this procedure be performed?

In some women the gonads produce hormones that can cause unwanted changes to the woman’s body and removing them can help to treat this problem. In other conditions if the gonads are left inside the abdomen, there is a small risk of them developing abnormal cells or even a cancer in the future. If you are at risk of this, your doctor will offer you a gonadectomy. The decision to have a gonadectomy may depend on your risk of cancer, and your individual circumstances and preferences.

Conditions where gonadectomy may be offered include Androgen Insensitivity Syndrome (AIS), Swyer syndrome and some varieties of Turner syndrome. The best time to have this procedure will depend on your condition, and your individual circumstances and preferences. You will be able to discuss this with your doctor in the clinic, and you will also be able to spend time with a Clinical Health Psychologist who can support you with decision making and coping with the procedure in the future.

What will happen before the operation?

You will discuss all the risks and benefits of the procedure in clinic with your doctor, and you will have the opportunity to ask any questions you may have. You will sign a consent form for the procedure when you are seen in clinic. You should take a copy of the consent form home with you. The consent form will be checked again on the day of surgery. If you have any questions about your procedure before the date of surgery, you can contact the gynaecology secretary who will pass a message on to the clinical team.

After your clinic you will need to have a pre-op appointment, where you will see a nurse who will arrange some blood tests and any other investigations if required. You will then need to come to hospital on the day of the operation. You must not have anything to eat or drink from midnight the night before the procedure. You will be seen by the surgical and anaesthetic teams on the ward before the operation when you will have the opportunity to ask any questions you may have since your last consultation.

What does the surgery involve?

It is carried out in the operating theatre where you are put to sleep under a general anaesthetic. You will have three or four small cuts on your abdomen (about 1cm in size). The abdomen is filled with gas so that the bowel and other organs are well away from the operating area. The gonads are removed and brought out through the cuts in your abdomen. The gas will be removed at the end of the operation. The procedure will take about 30-60 minutes. Once the gonads have been removed, they will be sent to the laboratory so that a doctor can look at them under a microscope to check that they are normal. You will have some stitches in the cuts on your abdomen.

What will happen after the operation?

If the procedure is straightforward, you will be able to go home later the same day, although some people might need to stay overnight. Someone from the surgical team will see you on the ward before you go home to let you know how the operation has gone. You will usually be prescribed some hormone tablets (oestrogen) that you will need to start taking after the operation, as your body will no longer be making this hormone which is essential for your bones and heart. These hormones will need to be taken until at least the age of 50.

The stitches in your tummy will dissolve by about 10 days after the operation. The recovery time for this operation is 1 to 2 weeks, so you might need to take some time off school, college or work. You will be sent an appointment to come back to clinic 6 weeks after the operation.

What are the risks of the procedure?

Although generally the operation is very safe, all operations and anaesthetics carry small risks which your doctor will discuss with you when you sign the consent form. You may have some pain around the scars on your tummy which should be controlled with painkillers. Some people get some pain in their shoulder tip which is caused by the gas that was put into your tummy during the operation. This should settle within a few hours.

Infection of the wound can occur, and if your stitches are red and sore or discharging, you should see your GP as you may need some antibiotics.  The other risks of ‘keyhole’ surgery are bleeding, and damage to the bowel or other abdominal organs. These are very unusual complications. If they happen, the surgeon might need to make a bigger cut to open your tummy to repair the damage or to stop the bleeding. This is called a laparotomy. If there is any damage to the bowel, you might need a colostomy which is where the bowel is brought out into a bag on your tummy, in order to rest the damaged bowel. This is usually temporary. Thankfully, these complications are extremely rare

What are the alternatives to having the procedure?

Some women do decide to keep their gonads inside their abdomen and not have the procedure.  If you chose this option, you would need to be monitored closely long term with blood tests and scans to look for signs of abnormal cells or even cancer.

Unfortunately, we do not have the evidence to say how often these tests should be done, and often minor changes may not show up on scans. If you have any questions about this, you can discuss them with your doctor.

For further information you can contact a Nurse Consultant Monday to Friday 09:00 – 17:00 on

0151 708 9988 ext 1053

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

Welcome to the Liverpool Women’s Hospital Outpatients department

You have been referred for a Hysteroscopy to investigate your heavy or irregular or post-menopausal bleeding or as part of your infertility investigations.

Investigation diagnosis and treatment are all performed at the same visit, and you can expect to be in the outpatient department between one and two hours. Having everything done in one visit means you will have to spend more time here, but it reduces delays in treatment, and unnecessary revisits to the hospital. Some women may be required to return for medical treatment, further investigations, or surgery.

Your appointment may involve an ultrasound of the pelvis which will be performed in the Imaging Department before your Hysteroscopy if you have not already had an ultrasound in the last year.

This leaflet aims to explain these tests and the treatment options available. Further explanations will be given at your consultation. Information can also be obtained from the website addresses available at the end of this leaflet.

How can I prepare for this appointment?

For those women who still have menstrual periods, you must use an effective form of contraception from the time of your previous period until you have the hysteroscopy.

Alternatively, you may wish to abstain from unprotected sexual intercourse from the first day of your last period prior to hysteroscopy.

You will Also be required do a pregnancy test before the procedure.  We will ask you for a urine sample when attending your appointment. We cannot do the procedure if there is any chance of pregnancy.

A relative or friend can stay with you throughout the whole of your visit.

You can eat and drink normally on the day of your appointment. If you have a morning appointment, we advise that you have breakfast and if you have an afternoon appointment have your lunch prior to attending.

Please note

If you have any heavy vaginal bleeding, the Hysteroscopy cannot be performed.  Therefore, please contact the access centre for advice on 0151 702 4080 at Crown Street.

Some women find that it helps if they take some painkillers a couple of hours before their appointment. This will minimise any discomfort. A good choice is Ibuprofen 400 mg or 1000mg of Paracetamol, which can be bought at a chemist. Always check with your pharmacist or GP that this is safe for you and read the instructions in the packet.

Intrauterine coils

The coil (IUCD) will interfere with the hysteroscopy examination, so the doctor/nurse will need to remove it. We recommend that you avoid intercourse for a week before your appointment, or that you use a barrier method of contraception in order for the coil to be removed.

Ultrasound scan

It is important that an ultrasound scan is performed prior to any further tests. You will be asked to go to the toilet and empty your bladder completely prior to the test. If you have any anxiety about the procedure, please discuss this with the staff performing the examination.

An ultrasound scan obtains a picture of the inside of your body without the use of x-rays. It is a very safe technique that allows the pelvic organs (uterus and ovaries) to be examined in detail.

The scan is performed using a probe which is gently inserted into the vagina – it will be similar to having an internal examination. By moving the probe in various directions, all the pelvic structures are displayed on the screen. While the probe is moved you may experience some minor discomfort, but it is not a painful procedure. During the examination a hand may be placed on the lower abdomen to push the pelvic structures nearer the probe so they can be seen more easily on the screen.

This method of scanning does not require you to have a full bladder as the probe is close to the pelvic organs, so a good view is obtained of the uterus, ovaries and fallopian tubes – the pictures are much clearer than abdominal scans.

The time taken to perform the scan varies but is usually between 5 – 10 minutes.

Hysteroscopy

This is a procedure performed to investigate the cause of abnormal bleeding.  It is performed in the outpatient department and does not usually require an anaesthetic. Some women find that it helps if they take some painkillers around an hour before their appointment if the procedure is uncomfortable for you, a local anaesthetic can be offered. The procedure is designed to investigate and sometimes make a diagnosis on the same visit.

Two members of nursing staff are present whilst the hysteroscopy is taking place; one member to assist with the person performing the hysteroscopy and one member to act as your support during the procedure.

The Doctor or Nurse introduces an instrument called a speculum into your vagina and this enables him/her to see the cervix (neck of the womb). This is the same as when you have a smear. Then a small telescope is inserted through the cervix into your womb.  It is connected to a camera and TV screen, which shows the inside of your womb.  After this, a tiny piece of tissue (biopsy) from the lining of the womb may be taken and this will be sent to the Laboratory for examination.   The hysteroscopy takes about 10 minutes, you may feel some period type pain, but many women feel nothing at all.

If you do find this procedure uncomfortable, there is the option to have a general anaesthetic.

 Why is a Hysteroscopy performed?

This is performed on women who have reported abnormal uterine bleeding or as part of infertility investigations. Abnormal uterine bleeding usually falls into one of the following categories:

Women over 40:-

• Any bleeding in between periods (intermenstrual)
• Any bleeding following the menopause
• A significant change in either the heaviness or frequency of periods.

Women under 40:-

• Heavy bleeding between periods or heavy periods that do not settle after a few months of treatment.

What are the risks associated with a Hysteroscopy?

A hysteroscopy is a very safe procedure but on very rare occasions it is possible to suffer a small perforation to the wall of the womb, this will usually close without any treatment, but may result in you needing to stay in hospital overnight so that you can be observed.

Infection is a possible complication although it is rare. If this should happen you might develop a discharge vaginally that may have an unpleasant odour, abdominal discomfort, and maybe a temperature. If you develop any of these symptoms, seek advice from your GP.

What are the benefits of an Outpatient Hysteroscopy?

The main benefit is that the person performing the hysteroscopy can view the inside of the womb and take samples without the need for you to have a general anaesthetic. This means you can return to your normal daily life more quickly. If polyps are present, hysteroscopy allows us to look directly at the polyp and sometimes this can be removed at the same time.   However, it is more likely that the polyp will be removed in our Ambulatory outpatient clinics.

What alternatives do I have?

Hysteroscopy may be performed under general anaesthetic, but this would require you attending as a day case. This may be appropriate if you are unable to tolerate the procedure as an outpatient or the doctor nurse is unable to pass the hysteroscope (camera) due to scar tissue on the cervix.

Endometrial biopsy  

 A sample of the lining of the womb can be obtained by passing a narrow plastic straw through the neck of the womb. To enable the plastic straw to be passed, it is necessary to see the neck of the womb by using the same instrument which is used for a cervical smear. Taking an endometrial biopsy may cause some mild discomfort similar to the hysteroscopy.

Retained tissue

Any tissue taken at the time of your hysteroscopy will be sent for examination to the laboratory and you and your consultant will be informed of the result. Following the investigation, the tissue will be disposed of in accordance with health and safety regulations.

After the Hysteroscopy

You will be offered a drink and a chance to talk to the Doctor or Nurse.  They will discuss the results of your test and may suggest some treatment options, but they may need to wait for results from the Laboratory.

Treatment options available during your consultation

Mirena IUS

The Mirena IUS is a small plastic T shaped device which is inserted into the cavity of the womb. This carries a hormone progesterone in a sleeve around its stem and has 2 fine threads attached to the base.  It releases a small amount of the hormone every day for 5 years. The hormone makes the lining of the womb thin and makes periods lighter and may stop them altogether.

Although the IUS isn't primarily used for painful periods, two studies have found that it does help in many cases (as often as 80% of the time). There is no 'build up' of blood, because the hormone in the IUS prevents the lining of the womb from building up at all. Often it is the excessive thickening of this lining that is the cause of the problems in the first place.

Once the IUS is in place, you won't be able to 'feel' it in your womb. Your doctor or nurse will show you how to check for the strings, and it is very unusual for your partner to be aware of it during intercourse.

It is a good idea to take some painkillers a couple of hours before the fitting - this will help reduce any discomfort. A good choice is Ibuprofen 400 mg, which can be bought over-the-counter at a chemist (please check that this is safe for you). Most women do not find the insertion procedure very uncomfortable - usually much less than expected.

Polypectomy

Polyps are small fragile growths that can occur in a number of places, and it may be possible to remove these in the clinic.

Polyps that can be removed are

• On the surface of the cervix – cervical polyp
• Lining of the womb – endometrial polyps

Surgery to remove the polyp is called a Polypectomy and this may sometimes be performed during the Hysteroscopy.  However, the majority of polyps are removed at another visit in our Ambulatory Outpatient Clinic which can be arranged after the Hysteroscopy.

What are the risks during Polypectomy?

This procedure involves the same as the risks involved

What are the benefits of having a Polypectomy?

This procedure can be performed during the Hysteroscopy, preventing the need for further surgery

What alternatives do I have?

Polyps can be left alone, although it is usually advisable to remove them, as there is a very small chance, they can turn malignant (cancerous). If polyps are found to be the cause of your bleeding, you will be advised to have them removed. You will be able to discuss treatment options with the doctor or nurse at your appointment.

Treatment options following your Hysteroscopy  

• Endometrial ablation – Endometrial ablation is a procedure that can help women with period problems without the need to resort to such major surgery as is involved with hysterectomy. It involves passing a treatment device through the neck of the womb (the cervix) and then removing or destroying the lining of the womb (the endometrium). More information regarding this procedure can be obtained at your consultation.
• Treatment of fibroids – Fibroids are usually benign (non-cancerous) growths in the muscle of the womb. They may be found at hysteroscopy growing within the cavity of the womb (sub mucous fibroids) and having fibroids may contribute to your periods being heavy.   There are various treatment options for fibroids, and this will be discussed during your consultation.
• Hysterectomy (removal of the uterus) – This is usually considered as a last resort if other less invasive treatment measures have failed or are unsuitable for you . This will also be discussed at your consultation but may depend on test results.

Important advice following the Hysteroscopy

If you feel unwell, start bleeding heavily, or experience pain that is worse than a painful period, you should:-

Contact your own GP or the Emergency room at Liverpool women’s hospital on 0151 702 4140

Some Websites you may find useful:-

www.womens-health-concern.org

www.netdoctor.co.uk

www.patient.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.

The leaflet is detailed below, or you can download the 'caring for your surgical wound' leaflet in PDF. 

Information Leaflet

This leaflet has been written to give you information and advice on caring for your surgical wound both prior to and after your surgery

Surgical wounds

A surgical wound is the cut made into the skin by the surgeon during the operation. At the end of the operation, the skin is stitched back together to allow the skin edges to come together and heal. This is done with stitches, steri-strips or adhesive dressings (glue).

The skin usually forms a seal within a day or two of the operation. The time this takes varies from person to person and is dependent on what sort of operation you have had. In healthy people, most wounds heal within a couple of weeks but again this can vary.

Dressings

Not all surgical wounds require a dressing. The purpose of a dressing is to: 

• Absorb any fluid weeping from the wound
• Provide the best conditions for healing
• Protect the area as your wound heals
• Apply pressure (if required)

Stitches, clips and staples

The medical term for stitches is sutures. Other methods that may be used to close the wound include adhesive dressings (glue), steri-strips or tapes.

Some stitches are dissolvable and will typically disappear within four to eight weeks, depending on the type. Others will need to be removed by the GP or practise nurse, as well as any clips or staples. When depends on the type of operation you have had and where the stitches are. Staff on the ward will provide you with further information about this prior to discharge and arrange a follow up appointment for their removal in the community. 

If you have stitches you may see small pieces of the stitch material poking out of your wound – do not be tempted to pull on these. Usually they will dissolve or be cut away by your nurse. As your skin heals, it is natural for your stitches and wound to itch – it is part of the healing process. Try not to scratch the area and do not apply any moisturiser or ointment on your skin to try and reduce the irritation.

Wound healing complications

Most surgical wounds will heal without causing any problems or complications; however it is possible that your wound may become infected following surgery – where germs have begun to grow in the wound, which typically delays the normal healing process. This is referred to as a ‘surgical site infection (SSI)’. If you develop an infection you will usually be given a course of antibiotics and occasionally, may need to have a further procedure such as surgery or drainage. You have an increased risk of developing infection if you:

• Smoke
• Have diabetes
• Are overweight or obese
• Have a condition that affects your immune system, such as leukaemia
• Are undergoing a treatment that affects your immune system, such as chemotherapy

A SSI can develop at any point, from two to three days after surgery, until the wound has healed (usually two to three weeks after the operation). It is therefore crucial that you know the different signs and symptoms to look out for when you go home:

• Increased pain
• The skin around your wound becomes more tender, sore, red and swollen or feels hot
• Your wound has a green or yellow coloured discharge (pus) or blood
• An unpleasant smell
• You generally feel unwell or feverish, or you have a temperature

If you have noticed any of the above symptoms or are generally worried about the appearance of your wound, please speak to your GP or practise nurse. If you develop symptoms whilst in hospital, your nurse will take a swab to be sent to the laboratory for testing

Steps you can take prior to surgery to help prevent infection

Showering: you are advised to have a shower or a bath using soap, either the day before, or on the day of surgery.

Hair removal: hair at the site of the operation should not be removed by razor or waxing in the week before surgery as this can increase the risk of infection by damaging the skin surface. If it is necessary to remove hair, this will be done safely at the time of surgery.

Staying warm: keeping warm before surgery will lower the risk of complications like infection. Bring additional clothing to help keep comfortably warm before and after surgery. Tell staff if you feel cold at any time during your hospital stay

Taking care of your wound

Your nurses and doctors will do all they can to prevent a SSI, however it is important that you know what you can do yourself to help prevent infection and to promote healing.

Changing your dressing

The original dressing will be in place for a minimum of 48 hours before your nurse removes and assesses the site. If required, another dressing will be applied for a minimum of 72 hours. If you go home with a dressing in place, it is important that you know how to remove and change the dressing if necessary and what to look out for on your wound site. If the wound is healing it can be left without a dressing, however you may prefer to have a dressing to cover the wound for protection, especially if your clothing can rub against it.

• Wash your hands with soap and water and dry them thoroughly before removing the dressing
• Carefully take off the dressing whilst trying not to touch the healing wound with your fingers
• Put the used dressing straight in the bin
• You might then be able to leave your wound without a dressing
• If you require another dressing, apply carefully taking care not touch the inside of the new dressing

Please be advised to continue using only the dressings supplied to you by the hospital or GP/practise nurse. If you do have any concerns about the current dressing you are using, please contact your GP

Bathing and showering

You will typically be advised to wait 48 hours post-surgery to shower safely. After 48 hours, a surgical wound can get wet without increasing the risk of infection; however it depends upon the type of operation. Your doctor/nurse will advise you specifically. When bathing/showering, there are some important points to consider:

• If possible, have showers rather than baths. It is important not to soak your wound too much as this may soften the scar tissue, causing the skin edges to open up. Only take a bath if you are sure you can keep the wound dry.
• Some waterproof dressings can be left in place whilst you take a bath or shower, while others may need to be removed beforehand. Your nurse will advise you depending on what dressing you have.
• Do not put any soap, shower gel, body lotion, talcum powder or other bathing products directly onto your healing wound. This may cause discomfort and also encourage an infection. You can gently wash the surrounding skin with mild non-scented soap though.
• You can let the shower water gently splash onto the healing wound, however do not rub the area as this may be painful and could delay the healing process.
• Pat the wound dry gently with a clean towel after showering/bathing.

Eating and drinking properly

Your body will need energy and the right nutrients to heal quickly, so it is important to eat well:

• Eating a healthy well balanced diet with plenty of variety including lean meat, fish, eggs, dairy, fruit and vegetables should give you all the nutrients you need for your wound to heal. Please visit the NHS website for advice relating to specific nutritional requirements/diets including vegetarian and vegan diets.
• Vitamin C and protein in particular are important to wound healing.

• Be sure to drink plenty of water – if you are dehydrated it may take longer for your wound to heal.
• You don’t normally need to take supplements if you were in good health before surgery and you recover normally.

Being overweight can increase the time it takes for your wound to heal and significantly increases your risk of wound infection. If you have diabetes, it is important to take care that your blood sugar is well controlled.

Where can I get further information about infections in hospital?

The Public Health England website www.hpa.org.uk has a section on surgical wound infections which includes the latest report.

More information about surgical wound infections can be found in the guideline on the Prevention and Treatment of Surgical Site Infection published by the National Institute for health and Clinical Excellence in 2008, and can be found online at www.nice.org.uk.

If you have concerns regarding infection or infection prevention, please speak to the nurse looking after you. You can also discuss your concerns with a matron or a member of the Infection Prevention and Control Team on 0151 702 4014.

The leaflet is detailed below, or you can download the 'Decision making, concentration and memory changes/problems during menopause' leaflet in PDF.

 

Many women describe changes to their memory, concentration and decision-making abilities during menopause (brain fog)

Decision making, Concentration and Memory

Brain fog is a very common symptom of the menopause. Women often say their brains feel like “cotton wool," they can become frightened, isolated and depressed.  Difficulty with concentration and memory loss have often been linked with the menopause, but is not clear whether there is a direct association with the hormone changes or whether these problems are due to a ‘knock-on’ effect from difficulty in sleeping, or, whether age-related changes are also a factor. Several studies that have looked at the effect of HRT on concentration and memory have often given inconclusive results; although many women report an improvement in brain fog when using HRT

Making decisions - from what to have for tea, through to important complex decisions - especially when under pressure, can sometimes prove very challenging. Some women stop driving as they feel they cannot concentrate and react to the road around them quickly enough. They feel unsafe and vulnerable.  Putting keys in the fridge, forgetting what you went to the shops for and not remembering phone numbers is inconvenient and annoying, but some women find their memory is so poor they worry they have dementia.

Women can give up work as they feel they can no longer cope with the job they previously managed successfully. New information in particular can be difficult to grasp and retain. Forgetting the content of conversations and meetings leads to performance worries and can undermine self-confidence.

Hormone Replacement Therapy (HRT)

It is not yet clear if the beneficial effects of HRT on memory, concentration and decision-making are a direct result of treatment with HRT or as a result of its improvement of symptoms such as night sweats and sleep patterns. Having disturbed sleep has a huge impact on how women feel the following day. When women wake up feeling exhausted, it is understandable that they won’t feel as focused and alert.

Managing Symptoms

Accepting that your memory isn’t as reliable as it used to be and being kind to yourself will help. 

If memory is a concern, confiding in friends and family often helps, as does speaking to your GP.  If these symptoms are affecting your work, talk to the Human Resources Department or a supportive colleague.  Allocate extra time for workloads, and create routines for regularly occurring activities such as prescriptions, bills, library book renewals etc. and try to delegate some responsibilities to others.

Strategies like list making and note taking when at home or in work are often useful and made simpler by recording “to do” lists on your mobile as and when something pops into your head.  Simple changes like this can ensure less is forgotten.

Making habits such as keeping a diary and checking it a week in advance as well as every evening for the following day – even when you are sure you know what is planned – will reduce anxiety about missed commitments.

Keeping healthy and active is also very important. Reducing alcohol, stress and cigarettes along with regular exercise, good nutrition and relaxation techniques, including mindfulness and breathing techniques, all play vital roles in our overall wellbeing.

Menopause cafes are being set up throughout the UK – these are forums for women to discuss their experiences of menopause and gain peer support. Attending one can be invaluable - or consider running your own!

 

 

 

 

The leaflet is detailed below, or you can download the 'Fast Facts about Menopause' leaflet in PDF.

Taking Hormone Replacement Therapy (HRT) does not just delay the inevitable menopause symptoms

When HRT is stopped symptoms do not necessarily return. Some women do experience troublesome symptoms after stopping HRT - these symptoms would likely have been present (but masked by HRT) all the time they were taking HRT

HRT can be taken for as long or as little time as the individual women feels is right for her

HRT can help with low mood associated with menopause and should be offered rather than antidepressants

Cystitis is not always a sign of infection

Oestrogen deficiency can cause similar symptoms. Vaginal oestrogen can be very effective

Alcohol can be a trigger for menopausal flushes, night sweats and insomnia

Red wine in particular can trigger severe symptoms for some women. Clear spirits are often better tolerated. Moderate drinking – no more than 14 units a week spread over a number of sessions with some alcohol free days each week – is considered within safe limits

Hangovers and alcohol intolerance get worse with menopause

As the female body ages less water is stored in the body so alcohol is more concentrated and stays in the body longer. Also as women enter menopause they often gain some weight – body fat cannot absorb alcohol so excess can lead to lower alcohol tolerance levels

HRT is not contraceptive

If avoiding pregnancy, contraception should be used for 2 years after your last period if under age 50

HRT provides heart and bone health as well as treating menopause symptoms

Women do not generally develop Osteoporosis (thin bones) or Cardiovascular Disease (heart attacks, strokes) until after menopause. This is because oestrogen prevents it

HRT and breast cancer risk

HRT used for more than 5 years can stimulate the growth of breast cancer cells which are already present in breast tissue.

Caffeine can trigger hot flushes and night sweats

Tea has half as much caffeine as coffee, cola drinks can contain considerable amounts

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Menopause and Weight Gain' leaflet in PDF.

Many women feel that their weight gets harder to manage the older they get.

We often approach menopause already struggling with our weight, and then IT JUST GETS EVEN HARDER.

Causes of Weight Gain in Menopause

Fluctuating and falling hormone levels around menopause can affect the way we store fat. This is because our bodies want to store fat for later - a bit like "puppy fat" at puberty. We develop "insulin resistance" making our bodies store, rather than burn, calories.

How the body handles food also changes: For example, if you eat 1000 calories before menopause you will burn 700 and maybe store 300. After menopause you will store 700 and burn only 300.

When women gain weight after menopause the distribution of where it settles alters: An extra pound before the pre-menopause will settle evenly over hips, bottom, thighs and arms. After the menopause it ALL goes round the middle! This leads to more of an apple than a pear shape - hence the term "middle age spread". So, even a small weight gain can result in a change of clothing size.

Our body needs less energy. Studies suggest we may need around 200 calories a day less than we did in the past.

We tend to move less too – aches and pains and stiffer joints as well as fatigue makes exercise seem impossible. The menopause can also play havoc with bladder control which can put some women off exercising. All of which means we burn up less energy.

We also lose muscle mass – known as sarcopaenia – at around 8% per decade after age 40. Muscle is more metabolically active – meaning it burns more energy – helping us to lose weight even when we are sitting still.  So, less muscle = less calories burned = more weight gain.

Other Effects

The psychological impact of menopause can also lead to weight gain – getting demoralised about our changing/ageing appearance, anxieties about relationships, finances or our own or a loved one’s health, as well as caring for elderly relatives or grandchildren and possibly feeling overwhelmed in work due to brain fog all cause extra pressure and stress which can lead to comfort eating - and drinking.

Women often complain that HRT causes them to gain weight. Some women resist taking HRT for fear of weight gain but there is no scientific evidence that HRT causes weight gain. A very small group of women may develop fluid retention with HRT (up to 10lbs in a month) but generally it is mild and will balance out in a month or two. In fact, HRT may prevent abdominal fat building up. HRT should also improve sleep and other menopause symptoms; therefore giving more energy and motivation to commit to healthy eating and exercise.

 What can we do?

• Eat smaller portions – we need less food than we used to. Every year over the age of 40 years - our Basal Metabolic Rate (BMR - the rate at which we burn off calories) slows down. Make sure that portion is full of good nutritious food that will protect health as well as help weight. Reduce the intake of sugar and processed foods– enemies of weight-loss and more likely to increase abdominal fat.
• Be mindful of alcohol intake – empty calories!
• Keep active. Studies show that exercise (especially in the cold) increases our fat-burning. And, the more we exercise the more we strengthen our muscles and bones. Women’s muscle mass declines around menopause. Muscle is efficient at burning calories - doing resistance work and lifting weights will increase muscle. An increase of 2kg of muscle = a 10% increase in BMR. Developing strong and toned muscles will make clothes fit better, as well as increase self-confidence.
• Wherever possible, address stress. Cortisol, the stress hormone, encourages abdominal fat deposition. Talk to friends, family, work colleagues and your healthcare professional about ways of reducing commitments, worries and menopause symptoms.

Choose the Menopause as a time of life to try and bring out the best in yourself. Take more exercise and eat a healthier diet, this will have the added benefit of helping you cope better with menopausal symptoms. And, don’t forget that the risk of breast cancer, heart disease, diabetes and other issues are also increased by our weight. So, losing excess weight protects us.

The leaflet is detailed below, or you can download the 'contraception with HRT' leaflet in PDF.

Although pregnancy is less likely during perimenopause and menopause, it is still possible. Even when periods are very infrequent or non-existent in younger women with Primary Ovarian Insufficiency (POI), a spontaneous ovulation can occur and result in pregnancy. Therefore, younger women who do not wish to become pregnant should use reliable contraception. 

Periods

Sometimes it is difficult to know if periods have stopped – bleeds caused from taking the combined contraceptive pill are false withdrawal bleeds and shouldn’t be confused with natural, spontaneous periods – and many women using progestogen based contraception (minipill, mirena coil, and injection/implant) don’t experience menstruation.

If you are uncertain when your last period was, a blood test to check your follicle stimulating hormone (FSH) level can be taken. If this hormone is elevated, (>30 IUU/l), you are very unlikely to become pregnant. It is important to note that you would need to stop taking the combined contraceptive pill at least 6 weeks before this blood test in order to get an accurate result (use adequate protection in the meantime). However, if you are using the Mirena coil or Progestogen Only Pill (mini pill), there is no need to remove/stop these. High doses of progestogens, such as those seen in the contraceptive injection, may affect the FSH result. It is therefore useful to think about swapping to another contraceptive method at around 50 years of age.  Current guidance recommends using contraception for 2 years after the last natural period if periods stop before age 50, and one year after the last natural period if periods stop after age 50. Generally at age 55, contraception is no longer required as the possibility of pregnancy would be very low.

Contraception

There are many forms of contraception - see for more information -

https://www.womens-health-concern.org/help-and-advice/factsheets/contraception-older-woman/

Most methods of contraception can be used alongside HRT (the combined contraceptive pill cannot). However, the mirena coil (hormone containing intrauterine system) is particularly useful since it can "double up;" not only providing contraception, but will usually reduce heavy and/or painful periods as well as providing womb lining (endometrial) protection.

Unfortunately the data presented to the regulatory authorities only provided evidence of endometrial protection with duration of just less than 5 years. Therefore, the mirena coil is currently only licensed for use for 4 years at a time with HRT - but most clinicians endorse use for up to 5 years off-label. To guarantee vital endometrial protection - which prevents cancer in the womb lining - if being used with oestrogen for HRT, the mirena must be changed every 5 years.

With rates of divorce and separation increasing, many women are sexually active again and should use a barrier method of contraception to prevent sexually transmitted infections (STIs) even if they have been sterilised or are using another method of contraception.

Chlamydia, gonorrhoea, HIV and other STIs are on the increase in women in their 40s and 50s, so it is a good idea to be screened for infection before starting a new relationship.

 

 

The leaflet is detailed below, or you can download the 'Lack of Sleep during Menopause' leaflet in PDF.

During menopause disturbed sleep and poor sleep quality can be a huge problem. Swinging oestrogen levels can cause night sweats, heat intolerance, insomnia and occasionally nightmares.

Sleep Patterns

Difficulty falling asleep, or falling into a deep sleep quickly only to be wide awake a few hours later - or intermittent waking throughout the night - often due to night sweats - are typical experiences during menopause. Lack of sleep can play havoc with our wellbeing, and quickly lead to anxiety and stress. All other menopause symptoms, and life worries, feel worse without good restorative sleep.

The best kind of sleep is non-REM (rapid eye movement), which consists of three separate stages (1, 2 and 3), which follow in order, upwards and downwards as the sleep cycle progresses. A cycle lasts on average 90 minutes and each cycle occurs four or five times a night, depending on how long you sleep for.

Stage 3 is considered to be the most valuable. This is deep sleep and usually occurs during the first half of the night, it's where our brain activity, breathing, heart rate and blood pressure are all at their lowest. It’s the time when we are most likely to dream too. This is restorative sleep and is essential for the body and mind to heal and repair.

Cognitive Behavioural Therapy (CBT) Top Tips

Night sweats tend to happen for most women in the early hours of the morning – when sleep is lighter. By this point in the night you have generally left the deep stage 3 phase of sleep and are moving between stages 2 and 1:

If you wake from night sweats, reminding yourself that you have by this point in the night likely completed your restorative sleep can be very reassuring. Accepting that you have had "good enough" sleep will prevent disaster thinking – where we exaggerate and magnify our worries - for example "I'll never get back to sleep", "I'll never manage to get through tomorrow" which will lead to spiralling stress and anxiety.

Calmly acknowledge that there have been previous similarly disturbed nights, and, although you may have felt below par the next day, you managed.

Try a Sleep app - listening to background noise, relaxation routines or stories is very useful. Many are free to download. Focussing on a voice/sound will prevent you thinking about worries and problems - we can only think one thought at a time. If/when your mind wanders gently guide yourself back to focus on the app.

Improve Sleep Hygiene

Simple measures, for example using layered bedding and natural fibre sleepwear, as well as having a cool ambient bedroom temperature, can help. Sharing a bed may lead to overheating - split duvets and cool pillows can be helpful.

Further sleep hygiene strategies, such as avoiding caffeine, chocolate, alcohol and heavy meals in the late evening, having wind down time away from technology, and a soothing, calm bedtime routine can improve sleep quality. Going to bed around the same time each night and avoiding daytime napping is really important. If you are still wide awake after 20 minutes get up and go into another room. Try doing something quiet and once you begin to feel sleepy go back to bed. Try not to clock watch.

 

 

The leaflet is detailed below, or you can download the 'Migraine and Menopause' leaflet in PDF

Migraine tends to worsen in the years leading up to the menopause, with attacks occurring more frequently and also lasting longer. Many women notice a link with their periods. For some women, the natural drop in oestrogen that occurs around menstruation - and during the pill-free week of combined oral contraceptive pills - can be a trigger. Others find that heavy, painful periods are linked to migraine. From early 40s, the menstrual cycle can become more erratic, with fluctuations in oestrogen levels, leading to more frequent migraines. As periods lessen and become infrequent, the hormonal trigger for migraine lessens; which is why many women find migraine improves after the menopause.

Can Hormone Replacement Therapy (HRT) Help?

Many women notice that migraine is more likely to occur when they have bad hot flushes and night sweats. Since HRT is very effective at controlling these menopause symptoms, it can help reduce the likelihood of migraine.

However, some forms of HRT can create more hormone fluctuations, triggering migraine. This is most likely to occur with tablet HRT. Therefore, its generally recommend that women with migraine who need HRT should use oestrogen patches or gel, as these maintain stable hormone levels with few fluctuations.

Unless a woman has had a hysterectomy, she will also need progestogen to protect the lining of the womb from thickening in response to oestrogen. For migraine sufferers, providing progestogen on a continuous basis helps to prevent hormone fluctuations. For perimenopause (and post menopause) women the mirena IUS (intrauterine system) coil is a good option. Progestogen is also available combined with oestrogen in patches, or separately as tablets of micronized progesterone, suitable for post menopause.

I have migraine aura. Can I take Oestrogen?

Yes. Unlike the combined oral contraceptive pill (which is contraindicated for women with migraine aura), HRT uses natural oestrogen producing similar levels to the oestrogen produced by your body during a menstrual cycle. If aura worsens or starts for the first time with HRT, it usually means that the dose of oestrogen is more than you need. The dose you need is the dose that is just sufficient to control hot flushes.

Vaginal oestrogen is useful to help control vagina symptoms of pain and dryness. Vaginal oestrogens can cause a temporary increase in migraine during the first couple of weeks but this quickly settles and there is no evidence that vaginal oestrogens are a trigger for migraine with long-term use.

It can take a few years for natural hormone fluctuations to completely settle after menopause. This is usually just one or two years, although some women find that they still get hot flushes and migraine ten or more years after the menopause. More often, even when hormonal triggers have settled, non-hormonal ones persist and may even increase post menopause. Chronic medical conditions, while not directly triggering migraine, will make migraine more likely to occur as they can lower the migraine threshold.

Maintaining good migraine ‘habits’ – regular meals, good hydration, avoiding caffeine, nicotine, alcohol and balancing other triggers, regular exercise, a good sleep routine, and looking after your general health, are all as important after the menopause as before.

If you are overweight, weight loss can benefit both migraine and menopause symptoms.

Regular exercise has also been shown to be effective. Non-hormonal alternatives include escitalopram or venlafaxine. These drugs act on the chemical messenger serotonin, which is implicated in both migraine and hot flushes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Options when avoiding HRT leaflet' in PDF

Hot flushes and night sweats are experienced by many menopausal women for an average of seven to thirteen years, and for some, these can last a lifetime. Women who are seeking to improve these menopause symptoms without using HRT can consider prescribable alternatives.

Alternatives

These medicines have been developed for other medical conditions, such as epilepsy, pain or high blood pressure, but have also been found to have a beneficial effect on some of the most common and debilitating menopause symptoms.

These alternatives can improve hot flushes and night sweats, and in some cases, mood and sleep too. The valuable heart and bone protection from HRT is unfortunately not gained with these treatments.  These medicines may be less effective than HRT, therefore women avoiding HRT may need to use a number of treatments, lifestyle changes and interventions to gain good symptom relief.

Clonidine

Clonidine is the only non-hormonal drug licenced for use for hot flushes in the UK. It’s an old-fashioned blood pressure medication. Clonidine may not work at lower doses – if using this medication its worth increasing the dose before deciding if it is not working. The dose can be increased slowly over two-week intervals:

Clonidine 25mcg is prescribed at a starting dose of twice daily and increased gradually to a maximum of 75mcg twice a day.

The higher the dose, the more likely clonidine is to work, but it’s then also more likely to cause side effects, such as sleep disturbances and a dry mouth. Obviously not everyone experiences side effects, or, some women will find side effects acceptable if they gain good symptom relief.

Since clonidine lowers high blood pressure (hypertension), it can also reduce normal blood pressure and may not be suitable for women with low blood pressure. If clonidine doesn’t work, women should wean off the medicine very gradually to avoid what’s called ‘rebound hypertension’.

Anti-depressants

Anti-depressants are often offered to menopausal women, sometimes because of a lack of confidence regarding HRT prescribing. NICE guidance clearly states that for most women HRT should be considered as first line treatment for menopause symptoms – including anxiety and low mood. However, for women avoiding hormonal therapies, antidepressants from the family of Selective Serotonin Reuptake Inhibitors (SSRIs) can be very useful. Unfortunately a stigma around taking antidepressants continues to influence some women, preventing them from accessing a widely recognised and valid treatment option.

Paroxetine is the SSRI that works best for flushes and sweats. Its prescribed at 10mg, half the dose usually used to treat depression. An increase to 20mg will have no extra benefit on flushes and sweats. As with most medications, the possibility of side effects increase as the dose of Paroxetine is increased, but it is the SSRI most likely to be well tolerated.

Other SSRIs which may be helpful include Fluoxetine, Citalopram and Escitalopram and can all be used for flushes and sweats. Sertraline is the least effective of the SSRIs for flushes and sweats, but is probably the best for women describing anxiety.

Fluoxetine and Paroxetine must not be used alongside Tamoxifen (a breast cancer medication)

As these Selective Serotonin Reuptake Inhibitor (SSRIs) interact with Tamoxifen and makes it ineffective. Instead, Venlafaxine, a mix of SSRI and Noradrenaline Reuptake Inhibitor (SNRI), is often recommended for breast cancer survivors taking Tamoxifen; starting at 37.5mg once a day and doubling to 75mg a day, Venlafaxine can significantly reduce hot flushes, improve fatigue, mental health and sleep disturbance.

All SSRIs and SSRI/ SNRIs can have associated start up symptoms, which are generally short lived and settled after a few weeks – since these medications work as mood enhancers, the first few weeks can be challenging– women report feeling groggy, “spaced-out” or sometimes even lower in mood or more agitated. It is after these start up symptoms have worn off that women can start to feel the benefit of improved menopause symptoms. Side effects, such as dry mouth, nausea, constipation and appetite problems which are commoner at higher dosage, and reduction in libido can occur.

Everyone varies in how they respond to treatment. 

For women with limited treatment options it is worth persevering and trying a second or even third antidepressant.

Gabapentin and pregabalin

Both of these medications are usually used to treat epilepsy, nerve pain and migraine.

Gabapentin reduces hot flushes at a dose of 900mg per day in about 50% of women. Pregabalin is prescribed at a dose of between 50mg and 300mg with the same benefit. In addition to suppressing flushes and sweats, Gabapentin causes drowsiness and, if taken at night, can improve sleep and may also help to reduce any pain, but some women find it very sedating in the day as well. Pregabalin doesn’t have this effect on sleep, but it works as a useful antidepressant.

The possible side effects of these drugs are dry mouth, weight gain, dizziness and drowsiness, which is worse with higher doses. A small dose is commenced and increased gradually, according to the effect on symptoms and side effects.

A major problem now recognised is that gabapentin and pregabalin are addictive, and, in the United States, these medicines are linked to an epidemic of dependence. In the UK, since 1st April 2019, these medicines have become subject to special rules requiring a ‘words and figures’ prescription in a set format, in which only one month of medicine can be prescribed at a time.

 

 

 

 

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Vaginal Dryness' leaflet in PDF

Changes to the vagina and bladder occur around menopause - these areas are very oestrogen sensitive and as levels of oestrogen fall many women notice discomfort.

Often the first sign of reduced oestrogen to the vagina is less lubrication during sexual activity. Some women actually describe increased vaginal secretions - this is usually a later sign of dryness when the vagina tissues are so depleted secretions leak through the thinning vagina walls. This increased discharge has a particular odour which some women feel is unpleasant. It is normal and not a sign of infection. The vagina becomes less acidic which means less natural protection from thrush. The bladder can also become "dry" leading to sensations like having a urinary infection - even though urine samples test negative for infection.

A range of effective treatments are available. Understanding the differences and choosing the right products are vital.

Symptoms of urogenital atrophy include:

• Vaginal discomfort
• Vaginal dryness before/during sex
• Pain during sex
• Vaginal/vulval itching and/or burning
• Thrush-like symptoms
• Frequent urinary infections or sensations like urinary infection
• Lack of bladder control

Replacing oestrogen directly to the vagina is considered the best way of reversing these symptoms. Oestrogen applied internally to the vagina via cream, pessary or vagina ring delivers a small but highly effective dose of oestrogen - which will also improve bladder symptoms. These products are very safe and are generally suitable even for women who have been advised to avoid HRT. NICE guidance recognises the importance of long term treatment - indeed a lifetime license has been granted to Vagifem. Many women using HRT also require vaginal oestrogen to improve urogenital atrophy, and it's absolutely correct to combine products.

Newer oestrogen-like products are now available - Ospemifene is a selective oestrogen receptor modulator which mimics the effect of oestrogen on the vaginal tissues, whilst Prasterone is a steroid based treatment that provides both oestrogen and testosterone-like improvements to the vagina.

Non hormonal treatments are also very useful:

Moisturisers nourish and hydrate the vagina - like a body lotion - some are available on prescription and they can all be used regularly with or without vaginal oestrogen products. They provide day to day relief, making walking, sitting and exercising more comfortable, however, they are not particularly useful for improving sexual comfort.

Vaginal pain and discomfort during intimacy is unfortunately very common. At menopause the vagina loses lubrication and elasticity - smear taking can become very unpleasant - All of the above treatments (oestrogen in particular) will improve comfort, but lubricants will provide extra support and prevent chaffing during sex. Lubricants are generally oil, silicone or water based. To gain maximum relief during penetration consider using both an oil and a water based lubricant - apply the oil base lubricant to the vagina, and the water based lubricant to the penetrating part - the products will glide over each other and reduce friction. Using condoms can also reduce rubbing***

***oil based lubricants can damage latex in condoms and lead to contraception failure.

 

 

 

 

The leaflet is detailed below, or you can download the 'Taking Utrogestan' leaflet in PDF

Utrogestan is micronized, body identical, progesterone. It is derived from plants including yams. **Do not take Utrogestan if you are allergic to Soya.

Women who take HRT and still have their womb (uterus) are required to take a progestogen in addition to oestrogen. This is because taking oestrogen alone can cause an unhealthy thickening of the womb lining (endometrium). If this happened, there is a potential for it to develop into cancer. Taking progestogen prevents this occurring.

Since natural progesterone can have a mild sedative effect, Utrogestan can cause drowsiness for some women. It is therefore recommended to be taken at bedtime.

**If you work night shifts this medication might not be appropriate for you.

It can improve sleep quality and doesn’t usually cause grogginess or a hungover feeling the following day. It is best to take Utrogestan on an empty stomach because eating food at the same time as taking this medication can increase drowsiness.

There are two ways of taking Utrogestan

1. For women who are still having periods within the last 6 to 12 months, the usual recommended dose is two 100mg capsules taken together each evening for 12 consecutive nights on a repeating basis. This regime will create an artificial monthly bleed:

 

The easiest way to keep track of this regime is to remove 24 tablets from the box (they are dispensed in 30’s), decide upon a convenient start day, and stick to it:

So, if Utrogestan is started on a Saturday night, the course will be restarted in 4 Saturday’s time.

2. For women who have not had a period for over a year, the usual recommended dose is one 100 mg capsule every evening without a break.

The information supplied with this medication describes a slightly different regime, but it is far more straightforward to take it in this way. It is completely safe to take it in either of these ways.

What are the side-effects of Utrogestan?

Some women experience side-effects initially which can include erratic vaginal bleeding, abdominal bloating, lower abdominal pains or discomfort and breast tenderness. Bleeding can be intermittent or continual and can last for the first 3 to 6 months. If bleeding worsens or does not improve with time then you should seek guidance from your menopause specialist or your GP.

Some women find that they feel lower in their mood when they take Utrogestan. This side-effect is less common compared with some of the older progestogens but can still occur in around one in ten women. There are alternative ways of taking Utrogestan which can be discussed if you experience this side-effect.

What are the advantages of Utrogestan compared to other types of progestogens?

As Utrogestan is body identical, women usually experience less side effects compared to the older types of progestogens.

The older types of progestogens which can be given as tablets or as a combination patch, can be associated with a slightly higher risk of clot and heart disease. Studies have shown that women who take Utrogestan do not have a higher risk of clot or heart disease.

The small increased risk of breast cancer in women who take HRT is understood to be related to the type of progestogen, and not oestrogen in the HRT. Taking Utrogestan does not appear to be associated with an increased risk of breast cancer during the first five years of taking it. After this time, the risk of breast cancer is very low and studies have shown that this risk is lower than the risk for a woman taking the older types of progestogens.

The leaflet is detailed below, or you can download the 'When HRT stops working' leaflet in PDF

Once established on the “right” HRT preparation for you, it’s often presumed that menopause symptoms will be suppressed for as long as the HRT is taken. Unfortunately that’s not always the case.

Factors

Many factors can affect how well HRT works - from health and lifestyle changes to human error and bad habits.

Some health conditions can mimic menopause symptoms – for example high blood pressure, type 2 diabetes, thyroid and heart conditions. If significant symptoms are occurring see your GP for a check-up.

New health related conditions can also affect HRT – bowel disorders, particularly frequent diarrhoea/loose bowels, can affect tablet HRT effectiveness. If you have noticed a change to bowel function, seek your GPs advice about it – as well as discussing HRT requirements. Skin conditions requiring emollients/steroid creams may affect transdermal (through the skin) HRT absorption.

Long Term Use

Many women find that their HRT can seem to be less effective after a few years use. During perimenopause and early post menopause, the ovaries continue to produce some oestrogen, also, small amounts of oestrogen stored throughout the body in areas of fat continue to circulate in the bloodstream, helping to treat menopause symptoms. Over time, these reserves run out and this can lead to menopausal symptoms feeling worse. Reviewing HRT and possibly increasing dose/changing route will often help symptom control.

It’s easy to get into bad habits when taking any regular medication – forgetting to take tablet HRT can cause break-through symptoms. Poor technique when applying gels can prevent good absorption – remember to apply to normal temperature skin and allow to air-dry well before dressing. Fake tans and body lotions can affect absorption for some women. Patches need to stick well, not irritate, and be changed on the correct days.

Other Factors

Simple prescribing mistakes can happen – if you notice a change in symptom control, double check the product you are using – particularly the oestrogen dose. If you think it’s different to your usual prescription, ask your Pharmacist to investigate.

Occasionally due to supply issues a different brand of HRT may be issued. Sometimes this is unavoidable. It's possible that the progestogen component (in combined products) may differ, however the dose of oestrogen should remain unchanged.

Some women feel they respond best to a particular brand of gel or patch. If so, it might be useful to talk to your Pharmacist about the possibility of arranging a continuous supply of the particular brand you respond best to.

Generally, best symptom control is usually achieved with transdermal rather than tablet oestrogen. For women with resistant symptoms, swapping to transdermal preparations is recommended.

Lifestyle factors including weight gain, unhealthy diet, increased alcohol and caffeine consumption and smoking can all trigger an increase in menopause symptoms. Stress will always make menopause symptoms feel worse - and can lead to all of the above spiralling -  Recognising and starting to address these triggers will improve menopause symptoms – simply increasing oestrogen may well not.

 

 

 

The leaflet is detailed below, or you can download the 'Diagnostic Laparoscopy' leaflet in PDF

What is a Laparoscopy?

It is an operation performed under general anaesthetic, which involves passing a small telescope (laparoscope), through a cut in your belly button into your abdomen to look at organs inside the pelvis and abdomen. Carbon dioxide gas is inflated into the abdomen to swell out the abdominal cavity. This separates the bowel from the abdominal wall so that the laparoscope can be inserted safely. This procedure is done to find the cause of problems such as pelvic pain, painful periods, infertility or painful sex. We may be able to treat minor problems during your laparoscopy.

 

Why do I need to have a Laparoscopy?

A laparoscopy is used to examine your uterus (womb), fallopian tubes, ovaries and pelvic wall. It is used to investigate and plan treatment for various different conditions. For example we can look for:

• Endometriosis – where tissue similar to the lining of the womb starts to grow in other places, such as the ovaries and fallopian tubes
• Pelvic inflammatory disease – an infection of the genital tract, including the womb, fallopian tubes and ovaries which may result in abscess formation.
• Ovarian cyst - a fluid-filled sac that develops on an ovary
• Adhesions – scar tissue

What are the benefits of having a Laparoscopy?

To find a cause for your symptoms and to plan treatment if any problems are found. The operating and recovery time are shorter than with an open operation (laparotomy).

What are the risks of a Laparoscopy?

As with all operations there are always possible risks, please remember they occur rarely.  Some will occur during the operation and others may not happen until you have gone home. The overall risk of serious complications from diagnostic laparoscopy is approximately 2 women in every 1,000.

Women who are obese, who have had previous surgery or who have pre-existing medical conditions must understand that the risk of serious or frequent complications may be increased. The risk of serious complications at laparoscopy also increase if a further procedure if performed

There is a small risk of damage occurring to bowel, bladder, ureters, uterus or major blood vessels during the operation. In these circumstances we would repair any damage. This would often involve a bigger wound to the abdomen and may mean you have to have a longer stay in hospital. There is a small chance of bowel injury only being apparent after discharge from hospital.

Sometimes, especially if you have had previous operation on your abdomen it may be safer to put the camera through a little cut on the left upper part of your abdomen (as opposite to through your belly button) to reduce the risk of complications. If that is the case your surgeon will discuss this with you prior the laparoscopy.

It is possible that a wound infection will develop.  Any inflammation or discharge at the wound site should be reported to your GP.

There is a very small chance of developing blood clots in your legs or lungs following the procedure, which is why you will be encouraged to start mobilising following the operation.

It is unlikely that you will lose much blood during the operation but if you do it may be necessary to give you a blood transfusion.

There is a risk that we are not able to gain entry into the abdominal cavity or we are unable to complete the intended operation.

The laparoscopy may not identify any cause for your symptoms

Fasting or ‘nil-by-mouth’ instructions

Fasting means you cannot have anything to eat or drink (except still water) for the 6 hours prior to your operation. This means you cannot suck on sweets or chew chewing gum. You are allowed to drink clear water up to 2 hours before your operation.

If you continue to eat or drink after this, your surgery will be cancelled.

For morning surgery, do not eat after midnight, the night before. You may drink water until 06:30am.

For afternoon surgery, you can have a light breakfast, tea/coffee with toast/cereal before 07:00am. You may drink water until 11:30am.

If you are taking any medicines, you should take your usual dose before 6:00am with a sip of water, unless advised not to, at your pre op appointment.

How long will I have to stay in hospital?

Many women come into hospital, have the procedure and go home on the same day. Sometimes patients stay in overnight if they feel unwell or because of the effects of the anaesthetic. You are more likely to stay overnight if the procedure is carried out late afternoon or early evening. Whatever day / time you are discharged, you will need a friend / relative to collect you from the hospital and stay at home with you for the first 24 hours.

How will I feel after a Laparoscopy?

You may experience abdominal bloating and cramping and pain in your ribs or shoulders; this is due to insertion of gas into your abdomen at the time of the procedure. This is not serious and should ease off over the next few days. You can take simple painkillers when needed. It is important to move around regularly to help prevent complications such as blood clots in your legs. You may have some vaginal bleeding or discharge for a few days and you should use sanitary pads rather than tampons / menstrual cup to reduce your risk of infection.

What happens when I go home?

What happens to the stitches?

You will have 2 cuts (possibly 3) on your tummy and the stitches will usually dissolve and fall out, this can take up to a week and sometimes longer. If you find the stitches irritating they can be taken out at your GP’s surgery. You need to keep the wounds clean and dry.

How long will it take me to recover?

You will probably need 2-3 days to recover from the procedure and the anaesthetic. Most people will need a week off work but you can return to work as soon as you feel able.

Will I be able to drive?

You should not drive for the first 48 hours and until you can move about freely. Therefore please arrange to be collected from hospital when you are ready to be discharged from hospital. Please check with your insurance company regarding driving following the procedure.

When can I resume intercourse?

This depends very much on what occurs and the findings during surgery. This can be discussed with a member of the ward staff before your discharge home.

You should seek medical advice from your GP, Liverpool Women’s Hospital Gynaecology Emergency Room, your Local Accident and Emergency Department or NHS 111 if you experience:

• Burning and stinging when you pass urine or pass urine frequently: This may be due to a urine infection. Treatment is with a course of antibiotics.
• Red and painful skin around your scars: This may be due to a wound infection. Treatment is with a course of antibiotics.
• Increasing abdominal pain: If you also have a temperature (fever), have lost your appetite and are vomiting, this may be due to damage to your bowel or bladder, in which case you will need to be admitted to hospital.
•  A painful, red, swollen, hot leg or difficulty bearing weight on your legs: This may be due to a deep vein thrombosis (DVT). If you have shortness of breath or chest pain or cough up blood, it could be a sign that a blood clot has travelled to the lungs (pulmonary embolism). If you have these symptoms, you should seek medical help immediately.
• There is no improvement in your symptoms: You should expect a gradual improvement in your symptoms over time. If this is not the case, you should seek medical advice.

Retained Tissue

Any tissue taken at the time of your operation will be sent for examination and you will be informed of the result. Following investigation the tissue will be disposed of in accordance with health and safety.  Only with your prior permission, would tissue be used for research or teaching purposes as part of an ethically approved study.

If you have any concerns please contact either your own GP or The Emergency Room at Liverpool Women's NHS Foundation Trust on 0151 702 4140

Equal Opportunities

The hospital is committed to promoting an environment, which provides equal opportunities for all patients, visitors and staff.  If you have any special requirements such as dietary needs, interpreter services, disability needs or a preference for a female doctor do not hesitate to discuss this with a member of staff who will try to help you

If you have any queries or concerns please phone either:

Liverpool Women's NHS Foundation Trust

Mon – Fri 7:30am to 9pm 0151 708 9988 Ext. 1124

Out of Hours and Weekends 0151 708 9988 Ext. 4120

Or telephone your GP.

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.

 

The leaflet is detailed below, or you can download the Active surveillance of 'Cervical Intraepithelial Neoplasia Grade 2 (CIN 2) ' leaflet in PDF.

This information sheet gives more information on the treatment choices for CIN 2 (Cervical Intraepithelial Neoplasia grade 2).

It is important to remember that CIN is not cancer, but it is a condition that requires either watching (surveillance) or treatment to make sure cancer does not develop in the future.

The nurse or doctor looking after you in colposcopy will discuss your treatment options and recommendations based on your individual circumstances.

What are my treatment options?

Until recently, patients with CIN2 would usually have been offered treatment called LLETZ or loop excision to remove abnormal cells.  However, there is now evidence to support surveillance of CIN2 and only treat it if it does not get better of its own accord.

What is active surveillance of CIN 2?

Surveillance means watching closely with smear tests and colposcopy instead of treatment with loop excision of cervix.

Why offer surveillance of CIN 2?

One reason for offering this management is that studies show that given time, CIN 2 may return to normal in about half of patients with no active treatment.  This is important so that risks associated with LLETZ treatment can be avoided.

Is active surveillance of CIN 2 a suitable option for me?

It is important to understand that surveillance of CIN 2 is not suitable for all patients.  The colposcopy team will take into account your individual circumstances before making a recommendation for your management.

Surveillance for CIN 2 is more likely to be suitable for younger people in whom a small area of CIN 2 is seen on the cervix.

What does surveillance of CIN 2 involve?

You will usually need to be seen in the colposcopy clinic every 6 months for a smear test and colposcopy until the cells return to normal.

If CIN 2 is still present after 2 years, we suggest active treatment with LLETZ.

If any time during the 2 years, the cells become worse in grade or size then we would recommend LLETZ treatment at that point.

It is very important that you attend the Colposcopy Clinic when any appointment is made for you.  If you cannot attend, for any reason, please let us know so the appointment can be used by someone else and we can arrange another appointment for you.

What else can you do?

We know that in people who smoke, CIN2 cells are more likely to get worse so that they need treatment.  If you smoke, we would encourage you to stop as this will make it more likely that the CIN2 cells go back to normal.

Further advice

We hope that you have found the information in this leaflet helpful.  If you require any further advice regarding any aspect of your care, please do not hesitate to ask the clinic staff on 0151 708 9988 ext 4266 (an answer phone is available).  They are there to support you and are happy to help with any concerns or anxieties.

You can also contact useful web sites for further information:

The British Society for Colposcopy and Cervical Pathology: www.bsccp.org.uk

Jo’s Trust

www.jotrust.co.uk

References (further reading)

British Medical Journal, 2018. Tainio et al. Clinical course of untreated CIN 2 under active surveillance: systematic review and meta analysis. This analysis published in 2018 in the British Medical Journal pooled results from studies involving over 3000 women. This showed that in 60% of women aged under 30 years with CIN 2 the cells became less abnormal within 2 years of surveillance. In 11% of women the cells had become more abnormal (CIN 3). There were no cases of cancer in these women.

 

 

 

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Information following your procedure on Ambulatory Care' in PDF.

Hysteroscopy + Pipelle Biopsy

Removal of Fibroid/Polyp (Myosure)

Retrieval of missed Coil

• You may experience bleeding or watery discharge after the procedure for 1-3 weeks.
• If you have had a fibroid or polyp removed you may experience bleeding for 2-4 weeks. You can expect heavier bleeding similar to a period within the first week.
• You may experience mild discomfort within the first 24-48 hours.
• We recommend no heavy lifting or strenuous activities for the rest of the day.
• We recommend that you use sanitary towels and not tampons whilst you are bleeding as this could cause an infection.
• We recommend sexual intercourse can resume after the bleeding has stopped.
• Please see the GP if you are concerned you may have an infection as they can review if you need to have a course of antibiotics.

Hysteroscopy and Endometrial Ablation (Novasure)

•  If you have had an ablation procedure you may experience bleeding for 2-4 weeks. You can expect heavier bleeding similar to a period within the first week post procedure.
• You will experience period like pain and cramping for the first 24-48 hours. We recommend you take regular pain relief.
• We recommend no heavy lifting or strenuous activities for the rest of the day.
• We recommend that you use sanitary towels and not tampons whilst you are bleeding as this could cause an infection.
• We recommend sexual intercourse can resume after the bleeding has stopped.
• Please see the GP if you are concerned you may have an infection as they can review if you need to have a course of antibiotics.

Minor procedures e.g. removal of vulval cyst

•  When cleaning the area use warm water. Avoid soaps that may irritate the wound site.
• When drying the area pat dry, do not rub the area as this may cause discomfort.
• If the consultant has used stitches these will take approximately 3-4 weeks to dissolve. If you notice any redness or discharge from the wound site please see the GP as you may need to have a course of antibiotics.
• If the consultant has used silver nitrate to stop the bleeding you may experience a dark coloured discharge for a few days, this is normal.

Please contact the Emergency Room if experiencing the following

• Severe pain
• Passing blood clots (If the clots are larger than clots you may experience when on a period)
• Unable to pass urine

Contact Telephone Number :

Gynaecology Emergency Room - 0151 708 9988 ext 4140

Results usually take between 4 and 6 weeks. If you have not received them please ring the switchboard on 0151 708 9988 and ask for your consultant’s secretary – Please do not ring Outpatients as staff in this department are unable to give results out. 

If you have an issue with a follow up appointment please call the patient appointment line on 0151 708 9988

 

 

 

The leaflet is detailed below, or you can download the 'Preventing a pressure ulcer and caring for my surgical wound during and after a stay in hospital'  leaflet in PDF.

A pressure ulcer (also known as a bedsore or pressure sore) is an injury to the skin and underlying tissue, caused by prolonged pressure on the skin by anything, but most commonly it’s a surface or device.

This can happen to anyone, however usually people affected have recently been in hospital, or have reduced mobility such as wheelchair users. 

Pressure ulcers can affect any part of the body but are most common on bony parts such as coccyx (base of spine), hips, heels and elbows. They can develop in a few hours.

Early signs of a pressure ulcer include:

Spot of skin becoming discoloured – this may appear red, purple or blue.

Discoloured patches will not turn white when pressed and will require elevation.

A patch of skin that feels warm, spongy or hard, or painful.

Later signs of a pressure ulcer include:

An open wound or blister (category two pressure ulcer)

A deep wound that reaches the deeper layers of skin (category three)

A very deep wound that may reach the muscle and bone (category four pressure ulcer)

Preventing pressure ulcers

It can be difficult to completely prevent pressure ulcers, but there are some things that you or your carers can do to reduce the risk.

These include:

Regularly changing your position – if you are unable to do this, please ask your nurse, carer or relative to help you.

If you’re an inpatient with us at LWH your nurses complete a thorough risk assessment to assess your risk of developing a pressure ulcer. They will monitor your skin regularly, assist you in changing position and give you special equipment such as an air mattress or cushion to help.

Checking your skin every day for early signs and symptoms of pressure ulcers – you may need help by your nurse or carer to do this in those hard to reach areas.

Maintaining a healthy, balanced diet that contains enough protein with a good variety of vitamins and minerals. If you’re concerned about your diet or caring for someone whose diet may be poor, your hospital dietician or GP, if you are at home will be able to help.

Making sure you are not sat or lay on things such as catheters, lines, or crinkles in your bedsheets.

Stopping smoking; smoking increases your likeliness of developing a pressure ulcer as it damages your circulation and oxygen supply.

Treatment of pressure ulcers in hospital

Changing position

Moving and regularly changing your position helps to relieve the pressure on ulcers that have already developed. It also helps prevent pressure ulcers form.

After your care team has assessed your risk of developing pressure ulcers, they'll draw up a repositioning timetable. This states how often you need to move, or be moved if you're unable to do so yourself.

For some patients in our care, this may be as often as once every 30 minutes. Others may need to be moved only once every 2 to 4 hours.

You may also be given training and advice about better sitting and lying positions, how you can adjust your sitting and lying positions, how best to support your feet to relieve pressure on your heels and any special equipment you need and how to use it.

Mattresses and Cushions

If you're at risk of getting pressure ulcers or have a minor ulcer, your nurses will recommend a specially designed static foam or dynamic mattress or if you’re really at risk you'll need a more sophisticated mattress or bed system, such as a mattress connected to a pump that delivers a constant flow of air into the mattress.

There is also a range of foam or pressure-redistributing cushions available. Ask your carer about the types most suitable for you.

Dressings

Specially designed dressings can be used to protect pressure ulcers and speed up the healing process.

Ask your nurse or carer about which type of dressing they're using to manage your pressure ulcer.

Creams and Ointments

Topical antiseptic or antimicrobial (antibiotic) creams and ointments are not usually recommended for treating pressure ulcers. Barrier creams may be needed to protect skin that's been damaged or irritated by incontinence. 

Antibiotics

Antibiotics may be prescribed to treat an infected ulcer or if you have a serious infection, such as blood poisoning (sepsis), bacterial infection of tissues under the skin (cellulitis) and infection of the bone (osteomyelitis).

Diet and Nutrition

Eating a healthy, balanced diet that contains enough protein and a good variety of vitamins and minerals can speed up the healing process.

If your diet is poor, you may need to see a dietitian. They can draw up a suitable dietary plan for you.

It's also important to drink plenty of fluids to avoid dehydration, because being dehydrated can slow down the healing process.

Caring for your surgical wound in and out of hospital

Caring for a surgical wound is important to lower your risk of infection and ensure your wound heals in the best way possible.

You will have a surgical wound after an operation at Liverpool Women’s Hopsital (LWH), during which, one of our trained surgeons will make a cut into your skin and tissues. Usually after your surgeon finishes they’ll bring the edges of the cut together and secure them with stitches, staples or glue.

In most people, wounds tend to heal within a couple of weeks but this can vary depending on the type of surgery you have had with us.

How your wound heals

After your surgery cells called platelets in your blood form clumps to stop the bleeding.

In the first few days cells arrive to keep your wound free of any infection and to remove any dead tissue which may be present, this process encourages new cells to arrive.

From three days to three weeks, new blood vessels use nutrients such as protein (which is why a good protein diet is important) to rebuild your wound like scaffolding.

Finally, from three weeks to around one year scarring becomes stronger and stronger. Most scar tissue has around 80% of the strength the skin had prior to wounding.

Monitoring your wound

During your wound healing process, it’s important to monitor it to check for signs of infection.

Most surgical wounds will heal without causing any problems, but it’s possible that your wound may become infected after surgery.

If you develop an infection, you’ll usually be treated with anti-biotics. We will do everything we can to prevent an infection but it is important that you know what to look out for after you go home. The usual signs of infection are:

• Pain
• Redness or swelling
• Unpleasant pleasant
• Weeping of liquid, pus or blood
• High temperature

Dressings

It’s not always essential to have a dressing applied to your wound, but if you do need one, its purpose is to:

• Absorb any fluid weeping from your wound
• Provide a good healing environment
• Protect the area as your wound heals
• Keep out any bacteria or infection

Stitches, staples or skin glue

The medical term for stitches is sutures; however your wound may be closed with metal clips, or skin glue. This method is selected by your surgeon depending on the size or location of your surgical wound.

If you have stitches (sutures) you may see small ends of the stitches poking out of our wound. This will dissolve or fall off – don’t be tempted to pull on this, if you’re concerned or it is still present after a few weeks let us know.

As your skin heals, it’s perfectly normal for the skin around the wound to feel itchy try not to scratch or apply any creams as this may introduce infection.

Most stitches we use at LWH are dissolvable so you won’t need to have them removed, they will usually disappear in around four to eight weeks.

A nurse or doctor will remove non-dissolvable stitches or clips 10 days after your operation day. Your nurse who is discharging you from LWH will arrange this with you.

Skin Glue 

Your surgeon may use skin glue to close your wound, especially if you have a small wound. An advantage of skin glue that it brings the edges of the wound together quickly, forming a barrier quicker than sutures or staples.

Skin glue is waterproof after 48 hours. It will flake off by itself in seven to ten days, so you don’t need a healthcare professional to remove it. Do not submerge your wound in water, shower  using only water with no soaps on your wound. It’s important not to use any ointment or moisturiser near your wound, or expose the wound to the sun as this may loosen the glue before its ready to come off.

Bathing and Showering

It’s usually possible to have a shower around 48 hours after surgery but this will depend on the operation you had.

Generally, shower rather than bathe so your wound isn’t submerged in water; this could soften your wound too much and encourage it to open.

Always check if your wound is waterproof and can be left on. If the dressing is not waterproof it could make your wound soggy if left on in the shower.

Only wash yourself in the shower with mild soap, to avoid any perfumed or strong soaps falling on your wound.

After showering, pat dry your wound with a clean towel, do not rub and allow to air dry.

Keeping yourself healthy

Your surgical wound is most likely to heal if your body is as healthy as possible.

Smoking

If you smoke, you should make every attempt to give up before your surgery. Smoking significantly reduces the amount of oxygen that can be distributed to your tissues; this in turn slows down wound healing. You can receive help and support to give up smoking from your GP or practice nurse.

Diet

Your body needs energy and the right nutrients to encourage good healing. A healthy balanced diet with lots of protein will help, you don’t usually need to take supplements. Ensure you’re thoroughly hydrated as this will also help healing.

Weight

Unfortunately those whom have a high body mass index (BMI) are more likely to have a wound infection or experience healing problems with wounds.

Diabetes

If you have diabetes, it’s important that your blood sugar is well controlled – having high blood sugar can increase the chances of having a wound infection or slowing down the healing process.

Where can I get further information about infections in hospital?

The Public Health England website https://www.hpa-uk.org/ has a section on surgical wound infections which includes the latest report. More information about surgical wound infections can be found in the guideline on the Prevention and Treatment of Surgical Site Infection published by the National Institute for health and Clinical Excellence in 2008, and can be found online at www.nice.org.uk.

If you have concerns regarding infection or infection prevention, please speak to the nurse looking after you. You can also discuss your concerns with a matron or a member of the Infection Prevention and Control Team on 0151 702 4014.

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

Welcome to the Liverpool Women’s Hospital Colposcopy department

What is cervical ectopy?

An ectopy is a common and normal finding on the cervix. It can also be called an ectropion, an erosion or an eversion. These words all mean the same thing. An ectopy is an area of soft delicate cells called glandular cells that are usually found on the inside of the canal leading to the womb. At certain times of life these cells move to the outside of the cervix.  These delicate glandular cells look very different from the normal pale pink skin cells as they are red and soft. Being soft they can bleed easily especially when having a speculum examination, a smear or during sex. This bleeding does not mean they are abnormal. 

How will know I have an ectopy?

An ectopy can be seen when you have a smear and can sometimes cause concern. If your smear is normal there is nothing to worry about. An ectopy is common and harmless. It is not linked to cervical cancer or any other condition that causes cancer. Sometimes you may be referred to the colposcopy clinic for a closer look if your practice nurse or GP is unsure.

What does an ectopy look like?

An ectopy is seen as an area of red cells around the os (opening to the womb). They can be a variety of sizes and shapes.

What causes ectopy?

A lot of people are born with cervical ectopy but it can be caused by hormonal changes. This means you are more likely to have it if you are:

• younger (under 30 years old)
• going through puberty
• pregnant
• taking the contraceptive pill.

What can I do about my ectopy?

You don’t need to do anything as an ectopy is normal. They usually disappear by the menopause.

Stopping the pill can reduce the size of an ectopy after several months but it rarely disappears completely.

We do not need to treat a normal ectopy that doesn’t cause symptoms as it is part of normal human biology. If an ectopy causes symptoms of bleeding with sex, it can be distressing; this can be treated with cold coagulation in the clinic which is also known as cautery.  Before considering cold coagulation for ectopy we will need to take biopsies to confirm the tissue is normal. Sometimes this will stop the bleeding without the need for further treatment.

What are the risks during Cold Coagulation?

• 1 in 10 women will have bleeding and/or infection
• The treatment may not work
• Symptoms may return months later
• Narrowing (stenosis) to the opening to the cervix which may cause problems in labour or with taking future smears
• Rarely damage to vaginal tissues

Some Websites you may find useful:-

www.jostrust.org.uk/information/cervix/cervical-ectropion

https://www.nhs.uk/conditions/colposcopy/treatment/

 

 

 

 

 

 

 

 

The leaflet is detailed below, or you can download the 'Care after 'Cancer of the womb' leaflet in PDF.

Introduction

You have now completed treatment for cancer of the womb and this leaflet has been written to support you moving forward; with guidance on recovery, getting back to “normal”, your follow up and to help you decide if, or when, you should contact your Gynaecology Oncology Clinical Nurse Specialist (CNS). Your CNS and cancer support worker will be happy to provide further information & advice on all of the aspects mentioned in this leaflet.

Recovering from Cancer Treatment

Recovering from surgery

There is very good evidence that encouraging patients to return to normal as quickly as possible reduces problems and complications. This is called enhanced recovery and you will have received information about this during your hospital admission.

Your recovery will depend on many things which makes it difficult to give an exact timeline. You should try to do a little more each day and use common sense to determine what is right for you. If you had keyhole (laparoscopic) surgery your recovery should be rapid and the majority of ladies are able to do most things after a few weeks. If you had a traditional, larger incision (laparotomy) recovery can be a little longer. It is usual for it to take several months for you to feel fully recovered.

Recovering from radiotherapy

Not all women have radiotherapy for their womb cancer; this section applies to those who have had this treatment. Additional information and advice will be provided by your CNS team.

The majority of side effects appear within the first or second year after treatment, but can start up to five years later. Treatment can cause the vagina to narrow and shorten, and become less elastic. This can cause discomfort or pain during intercourse or an internal examination. The regular use of vaginal dilators will help prevent vaginal narrowing and their use is recommended even if you are not sexually active. It is not unusual for women to experience a change in their emotions and feelings associated with sex. Most women will have some changes in the way their bladder or bowel works.

The impact of these side effects varies from person to person. For some women the effects may be minor and will not affect their daily life, some women may need to make changes to their lifestyle to be manage these effects. For a small number of the women the changes may be difficult to cope with. Much can be done to help if this happens; speak to your consultant about this - they can also refer you to a doctor who has a special interest in treating long-term side effects of radiotherapy.

Managing menopausal symptoms

Most women who experience womb cancer will have already gone through the menopause. Surgery for womb cancer can include removing the ovaries, which would then cause pre-menopausal women to go through the menopause. 

Hot flushes and night sweats are the most common menopausal symptoms, but many women also notice weight changes, sleep disturbances, vaginal dryness and changes in libido. If you are suffering from vaginal dryness, vaginal lubricants and moisturisers can be prescribed.

Hormone Replacement Therapy (HRT) is generally not routinely recommended for women who have been treated for womb cancer. However, if the symptoms are affecting quality of life, the risks and health benefits of starting HRT can be discussed with your consultant. Alternatively some women find herbal remedies and complimentary therapies such as acupuncture, hypnotherapy, massage or aromatherapy helpful for their symptoms.

Do tell your CNS or GP if menopausal symptoms are troubling you.

Getting back to “normal”

Reaching the end of treatment can be a difficult time whilst for others it is a sign that things can start to get back to normal. Many women are able to return to normal, or find and be comfortable with a new normal, but for others this may be more difficult. There is no right or wrong way to feel. Your CNS will be happy to provide more information on all the areas mentioned below.

Support: Some people prefer not to talk things through, while others get support from speaking about their experience. Details of support groups can be provided by your CNS.

Work: You can return to work whenever you feel ready to do so. All jobs are different so it’s hard to be specific. Whenever you return, remember it may be a shock to the system to begin with and it can be very useful to return in a phased manner, increasing your work hours over a few weeks.

Financial concern: You will be eligible for free prescription, if you are not in receipt of this please speak to your CNS. You may also be entitled to certain grants and benefits, this can be individually assessed or you can call the Macmillan helpline on 0808 808 00 00. If any other financial issues are causing you worry, speak to your CNS who can advise who can help.

Resuming sexual activity: It is vital to abstain from intercourse for 12 weeks following your surgery. It is not uncommon to lose interest in sex. Your treatment may leave you feeling more tired, or you may feel shocked, confused or depressed about being diagnosed with cancer. Try to share your feelings with your partner, if you have one. If you feel you have problems with sex that aren’t getting better with time, you may want to speak to a psychosexual counsellor.

Travelling abroad: Once you have completed your treatment, there is no reason not to travel abroad. Sometimes patients can experience difficulty in acquiring travel insurance, your local Macmillan Support and Information Centre and the Macmillan website will be able to offer advice. 

Fatigue: Though fatigue is a common symptoms there are steps you can take to reduce or cope with this. Top tips include – take it easy, conserve your energy, maintain your energy & get moving.

Exercise: Try to gradually increase your daily activity, with the aim of trying to build up to four or more thirty minute sessions each week of activities that increase your heart rate. If you require further information to access any local programmes please speak to your CNS team.

Diet: Evidence shows that maintaining a healthy weight, avoiding excessive weight gain, and maintaining levels of physical activity is associated with an improved quality of life and enhanced recovery. Top tips: keep to your meal routines, chose reduced fat, walk off the weight, pack a healthy  snack, look at labels, caution with your portions, think about your drinks & focus on your food.

Follow up

Following the end of your treatment you will begin a three year surveillance period, the aim of this is to ensure everything is going well and find out if you have any concerns. You will be stratified into one of the following methods of surveillance; this is decided by the MDT depending upon your final results. 

Clinical follow up. Traditional Face to face appointments at the hospital with a doctor, during which you will be asked questions about your recovery and any side effects or symptoms you have been experiencing. You may also have an internal examination.

Supported self-management. Rather than face to face appointments you will instead be supported by a care navigator & your CNS to be in control of your own three year surveillance period. Through an education event and on online portal you will be provided with essential information to help you manage your own follow up and live well beyond cancer. Further information will be provided if this is your follow up method.

When to contact your CNS

It is important to remember you will still get coughs, colds, aches and pains and bowel upsets just like anyone else. Your GP will normally be happy to treat such problems. However if they are concerned about your symptoms when they see you, they can contact your CNS who can arrange a clinic appointment.

For most patients their treatment is effective and their cancer will not come back but sometimes people do have problems. We would like you to contact your CNS if you have any of the following symptoms and they persist for more than two weeks:

• New onset of bleeding or persistent discharge from the vagina
• Bleeding from the back passage and/or changes in bowel habit
• Persistent abdominal bloating
• Bleeding after sexual intercourse
• New problems with passing water
• New persistent aches, pains, discomfort or lumps in your tummy
• New lower back pain
• Unexpected weight loss without dieting or exercise
• Persistent loss of appetite or nausea
• New persistent breathlessness
• New swelling of one or both legs

It is important to remember that even if you have some or all of these symptoms it does not necessarily mean the cancer has come back, but we will arrange to see you in clinic to check you over. Do remember, however, that some of these symptoms can also be caused by other conditions that are completely unrelated to womb cancer, so please do not become unduly anxious while awaiting your review.

You can contact your CNS team Monday – Friday 08.00-16.00 using the details provided at the end of this leaflet. If you phone and they do not answer please leave a message and contact number on the answerphone and you will be contacted as soon as the CNS picks up your message.

Worries about cancer returning

It is entirely natural to feel anxious that your cancer may return and we recognise that this can make you feel very uncertain about the future and lead to difficulties in “getting on with life”. Should there be any cause for concern, you will be reviewed by the clinical team and appointments or appropriate investigations will be organised for you.

Ways to manage worry and uncertainty about cancer

• Learn to focus on the ways cancer has made you a stronger person.
• Talk to family and friends about your concerns
• Join a support group
• Write a diary about your fears and feelings.
• Get involved with an interesting hobby or other things you enjoy doing.
• Review your priorities towards interesting and meaningful activities.
• Remember that as time goes by, your worries can fade.
• If depression, anxiety or any part of the cancer journey becomes overwhelming seek advice from your CNS or GP

How to contact the Gynaecology Oncology Clinical Nurse Specialist team:

Monday to Friday 8am-4pm telephone 0151 702 4186.

If you get the answerphone please leave your name, date of birth, telephone number and a brief message. Your call will be answered within 24 hours, or on the next working day if it is a weekend or bank holiday.

Support Networks Available Locally

Further information, advice and support are available for yourself/partner and family from:

Lyndale Cancer Support Centre - Knowsley

Tel: 0151 489 3538

 

Sefton Cancer Support Group

Tel: 01704 879352

www.seftoncancersupport.org.uk

 

St Helens Cancer Support Group

Tel: 01744 21831

 

Warrington & District Cancer Self-Help Group

Tel: 01925 453139

 

Widnes & Runcorn Cancer Support Group

Tel: 0151 423 5730

 

Isle of Man

Manx Cancer Help Association

Tel: 01624 679554

www.manxcancerhelp.org

 

Liverpool Sunflowers

Liverpool Cancer Support

Tel: 0151 726 8934

 

E.V.O.C.

Gynaecological Support Group

0151 702 4186

 

The Wirral Holistic Care Services

Tel: 0151 652 9313

www.wirralholistic.org.uk

 

Maggies Centre Clatterbridge

0151 334 4301.

 

 

The leaflet is detailed below, or you can download the 'Patient Initiated Follow Up' leaflet in PDF

Who is this leaflet for?

This leaflet provides information for patients who have attended a clinic at Liverpool Women’s Hospital and who have been offered a Patient Initiated Follow Up appointment.  It explains what patient initiated follow up is and how it works, along with all the information needed to contact the service to arrange follow up appointments.  We hope you find it helps you to feel confident to be in control of your own follow up appointment.

If you would like further information, or have any worries, please do not hesitate to ask your nurse, doctor or healthcare professional.

What is a Patient Initiated Follow Up appointment?

Liverpool Women’s Hospital is introducing a new system called Patient Initiated Follow Up (PIFU for short) which allows you to arrange follow-up appointments as and when you need them.  This puts you in control of your hospital follow-up and provides you with direct access to guidance when you most need it.

Most patients have been given follow-up appointments in clinic at regular intervals.   Many patients find these regular visits useful.  Others find that they cause anxiety and are not helpful unless they have a particular concern they wish to discuss with their doctor or nurse.  There is also evidence that, for some patients, regular follow up appointments do not benefit them.

How does a Patient Initiated Follow Up work?

If PIFU is suitable for you, your clinician will add your name to a PIFU follow up waiting list.  Instead of being given follow up appointments at regular intervals, you will be able to contact the Access Centre in the hospital to arrange a follow-up appointment if you feel you need it.  Your clinician will tell you how long you will stay on this PIFU waiting list, depending on your condition. If you do not need to see the doctor or nurse within the agreed time after your last appointment you will be discharged back to your GP who will re-refer you if you need to be seen again in the future.

Why are we introducing this new type of follow-up?

We are introducing PIFU because it offers a number of benefits.  These are as follows:

• Appointments for patients are made based on individual clinical need instead of being at routine intervals. PIFU puts you in control of your own outpatient follow up.
• If we free up any appointments this means we can reduce our waiting times for patients who may need an appointment, so they can be seen more quickly.
• PIFU prevents patients attending for unnecessary appointments.
• Reducing the number of unnecessary journeys will help reduce our carbon footprint.

What do I need to do?

Please contact the number below to arrange an outpatient appointment if you experience any problems with your condition and wish to discuss these with a clinician:

0151 702 4328 option 1

Frequently asked questions:

Why have you set a deadline for me to make an appointment?

The length of time that you will remain on the PIFU waiting list is determined by your clinician, as it will depend on your condition and their clinical judgement on how long most patients will need before they can be discharged back to their GP.

How do I book a Patient Initiated Follow Up appointment?

 The service is quick and easy to use. Please contact the following number 0151 702 4328 option 1 if you want to book your follow up appointment. If no one is available, then please leave a voicemail message for the team to return your call.

What if I cannot get through via telephone to make an appointment?

You can leave a voicemail message, and a member of staff will call you back.

What if I change my mind and wish to move back to traditional follow up appointments?

You will need to contact the Access Centre on the following number 0151 702 4328 option 1 and they will ask your clinician to review your follow up plan and transfer you to the traditional follow up model.

The leaflet is detailed below, or you can download 'Checking your coil threads' leaflet in PDF.

Checking your coil threads

There are two threads attached to the bottom of your IUD (intrauterine device) that come down the womb and out of the cervix (neck of the womb). When in place they sit high up in the vaginal canal. These threads allow you to check that your coil remains in place. They are also there so that your doctor can remove your IUD at a later date.

Your IUD may stop working if it slips either partially or completely out of place (known as expulsion). You may not experience any symptoms if this happens, therefore it’s important to check the threads regularly. Occasionally the threads can also curl up within the womb itself.

How to check your coil threads:

• Wash your hands
• Either sit or squat
• Insert your index or middle finger into your vagina until you touch the cervix (which should feel like the tip of your nose)
• If you can feel both the IUD threads then your IUD is in place. The threads will feel like fishing line.
• If the IUD threads feel longer or shorter than the last time you checked, or you cannot feel them at all, then your IUD may have moved.

When should I check my IUD threads?

The best time to check your IUD threads is at the end of each period as the cervix will be lowest in the vaginal canal at this point of your menstrual cycle.

It is particularly important to check your IUD every four weeks after fitting.  If your IUD is going to move out of place it will most likely do so in the first few months after it has been inserted.

If you can’t feel your IUD threads you should check your pads/tampons/menstrual cup to ensure that it has not come out. After this initial period, you should check your IUD threads every few months.

What should I do if I think my IUD has moved?

If your IUD has moved it will need to be put back in place by a doctor or the coil may have to be replaced. DO NOT try to push the IUD back up into place.

Contact your GP practice to make a follow up appointment with a nurse or doctor for an internal examination. You may require an ultrasound or abdominal X-ray to locate the coil if it is not visualised during the examination.

Until you can get to a doctor or nurse, make sure that you use a backup contraception, like a condom.

You may choose to have the IUD threads cut shorter if they can be felt by your sexual partner, however, this will obviously make it more difficult for you to check them.

 

The leaflet is detailed below, or you can download the 'Bringing your medicines into hospital before surgery' leaflet in PDF.

If you are regularly using medication including tablets, inhalers, patches, injections, eye drops or creams prescribed by your own doctor, please take these with you when you come into hospital. Please also bring medication you buy from your local pharmacy. You should bring enough supply to last for 5 to 7 days. You will be given a green bag at pre-op clinic – use this green bag to take your medicines into hospital with you.

It’s really important to bring your medicines in their original packaging, with the pharmacy label attached stating the name and dose of the medicine, and how often to take it. This is to allow pharmacy, nursing, midwifery and medical staff to correctly identify your medicines.

Please do not decant your medicines into a dosette box, or into another container.

If you get your medicines in a pre-made ‘blister pack’ from your community pharmacy, please ensure that all of the pharmacy labels are attached to the blister pack. This is to allow pharmacy, nursing, midwifery and medical staff to correctly identify your medicines.

In addition to the medicines themselves, it’s also very helpful if you bring an up-to-date list of all your medications, including details such as the dose and the time(s) of day they are taken. If you only take your medication on specific days, write this down (e.g. once a week on a Sunday). A GP repeat medication slip is a good source of this information.

On the medication list that you bring in, it is useful if you also list any drug allergies you have, as well as the nature of the allergic reaction (e.g. rash, breathing difficulties).

If you have a special card with details of any treatment, such as blood thinners or injections, bring this with you too.

On the ward, there are safe drug storage lockers by your bed where we will store your medication during your stay. We will add any newly prescribed medication to your locker while you are in hospital and give you a supply to take home. You will also take home the remainder of any medication you originally brought in.

Please make sure you have enough of your regular medication at home for after your procedure. This may require you to plan ahead and order your medication from your GP/collect it from your usual community pharmacy prior to coming into hospital. This means you won’t have to worry about ongoing medication supply while you are recovering.

This all helps to make sure you receive the best care. Bringing your own medication into hospital is very helpful and can reduce the time you wait for your medication prior to discharge.

Medication check list for coming into hospital

Use this checklist to make sure you have everything you need before coming into hospital. Tick the box when you have completed the action:

• A 5 to 7 day supply of all regular medications – such as tablets, patches, injections, eye drops and creams.
• All regular medications are in their original packaging with pharmacy dispensing label attached, or in a pharmacy prepared ‘blister pack’ with pharmacy dispensing labels attached (please do not decant your medication into a dosette box or another container).
• A list of all regular medications, including doses and when they are taken e.g. GP repeat slip.
• Details of any drug allergies, including the nature of the reaction.
• A supply of regular medicines at home, for after your surgery/procedure.

 

 

The leaflet is detailed below, or you can download the 'Discharge Advice from the Vulval Clinic Information for Patients with Eczema / Lichen Simplex' in PDF. 

You have been diagnosed with vulval eczema / lichen simplex, given a treatment plan in the vulval clinic and discharged back to the care of your GP. We do not follow you up in the vulval clinic as these are common conditions and GPs are very used to treating them.

You should read all the information leaflets that you have been given so you can use the treatments to their best advantage. If you run out of any treatment you should contact your GP surgery to get some more. Your GP will have a letter from us with your diagnosis and treatment plan so they should keep your treatments on a repeat prescription basis.

Once your skin is under control you should continue to use a soap substitute long term and avoid all soap / shower gels / bubble baths long term.

You should also continue to apply your moisturiser at least twice a day.

Whilst you have few symptoms a 30gram tube of steroid ointment should last you approximately 6 months and further tubes can be obtained from your GP.

If your itch / symptoms worsen you should increase your steroid according to their severity and if you need to recommence a full treatment regime again it is:

1 application every night for one month

1 application every other night for one month

1 application twice a week for one month (this will use a full 30g tube)

1 application once weekly for one month………..then stop OR

If your symptoms are still present, consider a once or twice weekly maintenance dose as per your steroid instruction sheet.

If your treatment doesn’t work, you are allergic to one of the creams or your symptoms flare up due to a thrush infection, please contact your GP in the first instance as they can deal with all of this. They will decide if they need to refer you back to the vulval clinic or not and contact us accordingly.