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Women's health - gynaecology

Please see below for the policies relating to women's health - gynaecology. To view the policy, patient leaflet and additional information, please click on the relevant heading.


  • Hysterectomy for heavy menstrual bleeding

    What is a womb removal for heavy periods?

    Heavy periods are when a patient loses an excessive amount of blood during consecutive periods. A heavy period can occur by itself or in combination with other symptoms, such as severe period pains. Heavy bleeding does not necessarily mean there is anything seriously wrong, but it can affect the patient physically, emotionally and socially, and can cause disruption to everyday life.

    Surgery for removal of the womb (hysterectomy) is one of the most frequently performed types of surgery but should not be used as a first-line treatment solely for heavy menstrual bleeding. It can be performed through the vagina (vaginally) as well as through the stomach (abdominally). Common indications for surgery include:

    • Heavy bleeding
    • Non-cancerous growths (fibroids)
    • A condition where cells like the ones in the womb (uterus) are found elsewhere in the body (known as endometriosis)
    • Weakness at the top of the vagina which causes the uterus (womb) to bulge downward (known as uterine prolapse)
    • Cancer of womb (uterus) and the lower end of the womb connecting to the upper vagina (cervix).

    Patient eligibility criteria:

    The patient's local NHS commissioning organisation will only fund this treatment if the patient meets the following eligibility criteria below. Hysterectomy should be considered only when:

    • Other treatment options have failed, or are declined by the patient
    • There is a wish for periods (menstruation) to stop (amenorrhoea)
    • The patient (who has been fully informed) requests it
    • The patient no longer wishes to retain their womb (uterus) and fertility.

    Patients offered a hysterectomy should have a full discussion of the implication of the surgery before a decision is made. The discussion should include:

    • Alternative surgery and psychological impact
    • Sexual feelings
    • Fertility impact
    • The woman's expectations
    • Bladder function
    • Size and shape of the vagina
    • Presence and size of fibroids
    • Need for further treatment.

    Individual assessment is essential when deciding the route of removing the womb (hysterectomy). The following factors need to be taken into account:

    • Presence of other conditions or diseases
    • Mobility and descent of the womb (uterus)
    • History of previous surgery
    • Patients offered hysterectomy should be aware of increased risk of serious complications associated with hysterectomy when non-cancerous growths (uterine fibroids) are present
    • Patients should be informed about the risk of possible loss of ovarian function and its consequences, even if their ovaries are retained during hysterectomy.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

  • Hysteroscopy for heavy periods

    A hysteroscopy is a procedure used to examine the inside of the womb (uterus). It is carried out using a hysteroscope, which is a narrow telescope with a light and camera at the end. It is passed into the womb through the vagina and cervix (entrance to the womb). This procedure helps to see what the problem is, make a diagnosis or even treat the problem.

    Heavy Menstrual Bleeding (HMB/heavy periods)

    Heavy bleeding during a woman’s menstrual cycle (period) is common and can affect everyday life. In some women heavy bleeding can happen if they have problems such as fibroids or endometriosis.

    Most women know how much bleeding is normal for them during their period and can tell when this changes. A good indication that your periods are heavy is if they last longer than seven days and you are:

    • Having to change your sanitary products every hour or two hours
    • Passing blood clots larger than 2.5cm (about the size of a 10p coin)
    • Bleeding through to your clothes or bedding
    • Using two types of sanitary product together – for example, tampons and pads.

    Usually there is no reason for heavy bleeding during a period. However, there are some conditions which can cause heavy bleeding:

    Endometrial conditions:

    • Endometriosis is a condition that occurs when the lining (endometrium) of the womb (uterus) grows outside of the womb such as the fallopian tubes, ovaries or along the pelvis. Some women with this condition may experience extremely heavy periods with or without clots in their period blood. It can also cause painful periods.
    • Endometrial polyps are non-cancerous growths in the lining of the womb or cervix.

    Polycystic ovary syndrome (PCOS)

    Polycystic ovary syndrome affects how the ovaries work. The ovaries may become enlarged and contain many fluid-filled sacs (follicles) that surround the eggs. These follicles are underdeveloped sacs and are often unable to release an egg (ovulation). This can cause irregular periods and periods can be heavy when they start again.

    Fibroids

    Fibroids are non-cancerous growths made up of muscle and tough tissue that develop in or around the womb and can vary in size. Other reasons may include:

    • An infection in the womb, fallopian tubes or ovaries
    • Womb cancer – the most common symptom is abnormal bleeding, especially after menopause
    • Blood clotting disorders
    • Diabetes.

    Some medical treatments can also sometimes cause heavy periods:

    • The coil – a contraceptive device which can make periods heavier for the first 3 to 6 months
    • Medication to prevent blood clots
    • Some chemotherapy medicines • herbal supplements such as ginseng, ginkgo and soya can affect hormones and periods.

    Eligibility criteria:

    Hysteroscopy for heavy menstrual bleeding is a restricted procedure. The patient’s local NHS commissioning organisation (CCG), who is responsible for purchasing healthcare on behalf of the population, will only pay for the treatment if the patient has one of the following:

    • Suspected fibroids, polyps or endometrial symptoms inside the womb and continual bleeding between periods or irregular bleeding

    OR

    • irregular heavy bleeding and is obese or has polycystic ovary syndrome OR • women taking tamoxifen (type of hormone (endocrine) therapy used to treat breast cancer)

    OR

    • Heavy menstrual bleeding after having treatment and it has not worked

    OR

    • Has an ultrasound which did not show clear results.

    This means the patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if an Individual Funding Request (IFR) application has shown exceptional clinical need and the CCG supports this.

    Advice and further guidance:

  • Labia reduction

    What is a labia reduction?

    A labiaplasty is a surgical procedure to reduce the size of the flaps of skin either side of the vaginal opening (labia minora).

    Patient eligibility criteria:

    This procedure is restricted to patients that meet a set, eligibility criteria for the treatment. This is because there is a lack of research and clinical evidence to show how effective this procedure is. This means there is no guarantee it will achieve a long-lasting desired effect, and there are short and long term risks to consider.

    Therefore, except where the criteria is met, surgery to reduce the size of the vaginal skin flaps (labia) is deemed to be a cosmetic procedure. The Royal College of Obstetricians and Gynaecologists (RCOG) state:

    • The patient must be fully informed and advised accordingly
    • Clinicians who perform labia reduction surgery must be aware that the clinicians are operating without a clear evidence base
    • Labia reduction surgery should not normally be offered to patients below the age of 18 years due to changes in the patient’s body during puberty
    • Labia reduction surgery should is not normally funded by the patient’s local NHS commissioning organisation unless the surgery is medically advised.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    • For more information search for ‘labiaplasty’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Treatment for heavy periods (menorrhagia)

    What is the treatment for heavy periods?

    Heavy periods, also called menorrhagia, is when a woman loses a lot of blood during consecutive periods. A heavy period can occur by itself or in combination with other symptoms, such as menstrual pain.

    Heavy bleeding does not necessarily mean that there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life. A hysteroscopy is a procedure used to examine the inside of the womb (uterus) to diagnose any issues.

    Not normally funded treatment or procedure:

    Dilatation and curettage refers to the widening/opening (dilation) of the cervix and surgical removal of the lining of the uterus and/or contents of the uterus by scraping and scooping (cutterage). This treatment option is not normally funded by the NHS for heavy periods (menorrhagia). This is because national guidance recommends that:

    • Ultrasound should be the first option to identify any abnormalities
    • Dilatation and curettage should not be used to diagnose issues
    • Dilatation and curettage should not be used as a treatment.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation.

    See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

  • Vaginoplasty

    What is female genital reconstructive surgery?

    Female genital reconstructive surgery (vaginoplasty) and cosmetic procedures for the vaginal canal and its mucous membrane, internal and external parts of the female genitalia (vulvo-vaginal structures), that might be absent or damaged because of disease or birth defect or because of an acquired cause, for example, through childbirth physical trauma.

    Female genital reconstructive surgery (vaginoplasty) and genital procedures are restricted to patients who meet the eligibility criteria below. 

    Patient eligibility criteria:

    The patient's local NHS commissioning organisation will fund this treatment only if the patient meets the criteria below. This is because vaginoplasty is considered to be a cosmetic procedure, apart from when:

    • Absent from birth (congenital) or significant developmental abnormalities of the vaginal canal
    • Where repair of the vaginal canal is required after trauma.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

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