Evaluation of a tertiary and district general hospital menopause service.

OBJECTIVE: Requests for management of menopausal symptoms and hormone replacement are increasing in the UK. Referrals to specialist clinics have to be balanced with increasing recommendations within the NHS to improve efficiency and patient care. STUDY DESIGN: Retrospective evaluation of clinic records over two months at a district general (Poole Hospital) and tertiary (Guy's Hospital) menopause service. Data on referral origin, reason for referral, interval from referral to review and outcome were collected and compared between trusts. MAIN OUTCOME MEASURES: To evaluate and compare referrals and outcomes in a tertiary and district general menopause service and provide recommendations for improving efficiency. RESULTS: Most referrals are from primary care but up to 25% are from other specialties. Half of the appointments are new referrals and 95% of women attend. Of the new referrals, 50% have multiple medical comorbidities, 25% a personal or family history of cancer and 25% treatment resistance; 30% have premature ovarian insufficiency. At Guy's Hospital, 30% are reviewed more than 18 weeks after referral, at Poole Hospital this is 6%. Treatment resistance is reported in half of the women reviewed at follow-up. CONCLUSIONS: Menopause services review a complex patient population and the majority of referred women have more than one co-morbidity; they require time, specialist knowledge of current treatment options and a multidisciplinary approach. The main barrier to service efficiency is capacity, particularly in population dense areas; cognitive behavioural therapy and non-hormonal methods appear under-utilised in primary care, as do alternative methods of follow-up within the clinics such as telephone and patient-initiated appointments.

An audit of liquid-based cytology samples reported as high-risk human papillomavirus and borderline nuclear change in endocervical cells.

INTRODUCTION: Primary human papillomavirus (HPV) screening, testing for the virus responsible for 99% of cervical cancers, was introduced in 2018-2020 in the UK. This was preceded by HPV triage of low-grade cytology from 2012. Much of the evidence incorporated into current National Health Service (NHS) colposcopy guidance assessed outcomes prior to this change in screening. The aim of this paper is to assess adherence to NHS cervical screening programme standards, determine the incidence of cases reported as high-risk HPV plus borderline nuclear change in endocervical cells, to calculate colposcopic accuracy and assess histological outcomes in this cohort. METHOD: A retrospective audit of women referred to a colposcopy clinic in one NHS trust from 2016 to 2018. Data relating to histological outcomes, cytological follow-up and demographics were collected. RESULTS: Of 2001 referrals, 22 data sets identifying HPV-positive borderline endocervical change were eligible for analysis (1.2% incidence). Median age was 29.5. Two-thirds (68.2%, n = 15) had high-grade dysplasia at diagnostic biopsy. Those women with reassuring histology had normal cytological follow-up. Colposcopic accuracy was moderate (positive predictive value 43.8%, negative predictive value 100%). CONCLUSIONS: Borderline nuclear change in endocervical cells is an uncommon condition but should be treated as a high-grade referral. All women should be offered a diagnostic biopsy at the initial colposcopy; if no histopathological abnormality is identified, alternative sources of pathology should be considered. Excisional treatment should be recommended to unreliable attenders, those with a complete family and inadequate colposcopy (TZ3) and considered in younger women with a TZ3.

Comparison of the Cervex-Brush alone to Cytobrush plus Cervex-Brush for detection of cervical dysplasia in women with a transformation zone type 3.

INTRODUCTION: Twenty percent of colposcopic assessments are inadequate due to a type 3 transformation zone (TZ3). In the absence of colposcopic or histological assessment, subsequent management is guided by the referral screening test. In the UK, routine cervical screening is completed by a Cervex-Brush alone. This study examines the effectiveness of a Cytobrush in addition to a standard Cervex-Brush when used in TZ3 assessment. METHODOLOGY: An 18-month diagnostic accuracy study in a single National Health Service (NHS) Trust. Women with a TZ3 booked for large loop excision of the transformation zone (LLETZ) with a referral cytology of high-risk HPV and squamous dyskaryosis were recruited. Immediately prior to LLETZ, a Cervex-Brush plus Cytobrush liquid-based cytology sample was taken. Presence of endocervical cells was compared. Predictability of high-grade cervical intra-epithelial neoplasia (CIN2+) was by blind standardised reporting of the LLETZ histology. RESULTS: One hundred and five women were recruited from a total eligible population of 153 cases (68.8%). Endocervical cell yield was increased with the Cervex-Brush plus Cytobrush when compared to the Cervex-Brush alone (99.1% vs 79.1%, P < .001). Irrespective of cytological grade, age or parity, there was no difference in predictability of CIN2+ between sampling methods. CONCLUSIONS: When compared to Cervex-Brush sampling alone, the addition of a Cytobrush improves endocervical sampling but does not improve cytological predictability of CIN2+ in women with a TZ3. These data suggest that women who will reliably attend for cytological follow-up can be safely referred to primary care for a Cervex-Brush alone.

Unsatisfactory colposcopy: clinical decision-making in conditions of uncertainty.

BACKGROUND: Unsatisfactory colposcopy, where the cells of interest are not visible in women with a positive cervical screening test, is a common area of clinical uncertainty due to the lack of clear evidence and guidance. Colposcopists' opinions and experiences are likely to have a significant influence on service provision and the development of national policy. The aim of this study was to analyse decision-making when applied to women with unsatisfactory colposcopy. METHODS: A multi-centre qualitative study utilizing a series of focus groups in an English healthcare region. Sampling aimed to ensure heterogeneity of experience and healthcare provider demographics. A topic guide covered a range of clinical and cytological variables and was compiled by the researchers and three expert Colposcopists. Using an iterative approach, thematic analysis was selected as the most appropriate method to identify factors affecting decision-making. RESULTS: Twenty-three Colposcopists from four units participated. The decision to treat was easier in women with high-grade cytology and high risk women with low-grade cytology such as heavy smokers, poor attenders, older women, those who had completed their families and women opting for treatment. Where decision-making was more complex, intuition and a multi-disciplinary approach were used to guide management. Areas of dissonance, which are affected by paucity of evidence and emotive factors, included cytological collection device, clinical setting and length of conservative follow-up and depth of excision in women at high risk of treatment-related morbidity. CONCLUSIONS: Anxiety of missing a cancer deters long-term cytological follow-up, resulting in heterogeneity of care and higher than anticipated excisional treatments in women with low-grade screening and unsatisfactory colposcopy. In areas of clinical uncertainty when decisions are dominated by affect, clinical guidance can reduce the difficulty and anxiety of decision-making.

The training value of a low-fidelity cervical biopsy workshop.

INTRODUCTION: Cervical biopsy increases diagnostic yield compared with cytology and reduces time between presentation with and diagnosis of cervical cancer. Procedural training however needs to evolve in line with legislated working time restrictions and patient safety concerns. This makes gynecologic procedures ideal for simulation training. To date, no studies have looked at the use of low-fidelity simulation models to teach cervical punch biopsy. METHODS: A cervical punch biopsy model was created using home and departmental waste products. The simulation model was tested by expert colposcopists and used during a gynecology trainee cervical study day. Twenty-one trainees attended a lecture that showed photographs of normal and abnormal cervices and a workshop where colposcopists demonstrated the technique before direct hands-on training with the simulator. Participants were asked to complete a survey, using a 5-point Likert scale, outlining the educational value of the workshop. RESULTS: Five low-fidelity cervical biopsy simulation models were created, these cost nothing, took an hour to make, and were easily transported. Of the different "cervix" materials tested, sponge provided the most realistic traction and the least fragmented biopsies (3-5 mm). Eighteen trainees completed the survey of whom all strongly agreed that learning was enhanced compared with didactics alone. The mean score for the value of the simulation in preparing trainees to perform future cervical biopsies was 4.7 (SD = 0.42) (95% confidence interval, 4.49-4.90). CONCLUSIONS: Our low-fidelity cervical biopsy models are easy to make, portable, and low cost. Trainees have reported the significant educational value of this simulation model in teaching an outpatient gynecologic/colposcopy procedure in a nonclinical environment.