The diagnosis and treatment of endometrial pathology in the outpatient setting

De Silva, Prathiba Madhubasha (2023). The diagnosis and treatment of endometrial pathology in the outpatient setting. University of Birmingham. Ph.D.

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Hysteroscopy is now the most common gynaecological procedure, where technological advances in endoscopy mean that both diagnostic and operative hysteroscopic procedures can be performed successfully in the outpatient setting. Although the majority of women report excellent care, this thesis aims to improve the care of women who use this service and investigate a novel way in which hysteroscopy can be used to improve outcomes related to miscarriage.

This thesis is split into two halves and has been written in an ‘alternative format’ as nine of the chapters have either been published or have been submitted for publication. The first half demonstrates the work involved in developing a new evidence-based national ‘green-top’ guideline for the Royal College of Obstetricians and Gynaecologists and the British Society for Gynaecological Endoscopy on how outpatient hysteroscopy should be provided and how it should be performed, through a series of systematic reviews, followed by the updated guideline itself. The second half determines the feasibility of performing a full-scale, adequately powered, multi-centre randomised controlled trial evaluating the effectiveness of the outpatient hysteroscopic removal of retained pregnancy tissue following a first-trimester miscarriage compared with standard expectant, medical, or surgical management, on the outcomes of fertility and future pregnancy outcome.

Based on the results of this thesis we recommend the following:
1. Patients should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their outpatient hysteroscopy.
2. Local cervical anaesthesia for outpatient hysteroscopy should only be recommended where vaginoscopy fails or where cervical dilatation is anticipated.
3. Vaginoscopy should be the standard technique for hysteroscope insertion in the outpatient setting unless a vaginal speculum is required to dilate the cervix or obtain a blind global endometrial biopsy.
4. Saline is recommended as the best distension medium for outpatient hysteroscopy at the lowest pressure to achieve a satisfactory view.
5. Cervical preparation in order to dilate the cervix and facilitate entry of the hysteroscope should not be routinely administered in the outpatient setting.
6. Conscious sedation should not be routinely used for outpatient hysteroscopy.
7. Mechanical instruments should be preferred over electrical energy in order to remove endometrial pathology in the outpatient setting.
8. A future, full-scale, adequately powered, multi-centre RCT investigating outpatient hysteroscopy against standard treatment for the management of retained pregnancy tissue following a miscarriage is highly feasible, with high numbers of eligible patients, high patient acceptability of proposed interventions and low attrition rates.

Type of Work: Thesis (Doctorates > Ph.D.)
Award Type: Doctorates > Ph.D.
Licence: All rights reserved
College/Faculty: Colleges (2008 onwards) > College of Medical & Dental Sciences
School or Department: Institute of Metabolism and Systems Research
Funders: Other
Other Funders: Ambulatory Gynaecology Fund, Tommy's
Subjects: R Medicine > RG Gynecology and obstetrics


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