Treatments or Investigations

The extensive experience of our private Consultants at The Gynaecology Group allows up-to-date treatment of a complete range of gynaecological conditions. Treatments for gynaecological conditions may vary from reassurance to simple non-hormonal or hormonal medication to minor or major surgery.

The Consultants in The Gynaecology Group combine clinical excellence and extensive experience in the treatments we offer. As well as being experienced 'open' and 'vaginal' surgeons all four consultants are Advanced Laparoscopic Surgeons, making any surgery as safe as possible.

CERVICAL SMEARS

Cervical screening is a test to check the health of the neck of your womb (cervix). The test checks for changes in the cells of your cervix that may, if untreated, develop into cervical cancer. Catching any changes early can help to prevent cervical cancer.

Cervical screening is sometimes called a smear test. It’s a test used to check the cells in your cervix for any changes. Cervical screening isn’t a test for cancer, but it can pick up changes to cells in your cervix that could become cancer in the future if they aren’t treated.

During a cervical screening test, a small sample of cells is taken from an area on the surface of your cervix called the transformation zone. These cells are then sent to a laboratory where they are examined using a microscope to check for any changes.

The NHS runs a cervical screening programme in the UK. In England and Northern Ireland, women between 25 and 64 years old are invited for screening. In Scotland, women aged 20 to 60 are included in the programme, and in Wales women between 20 and 64 are screened. Cervical screening may be less effective in women aged 20 to 24, because it’s common to have changes in the cells of your cervix when you’re younger. Treating these changes unnecessarily could lead to complications.

If you’re registered with a GP, you will be invited by your surgery to have cervical screening at least once every three years. Depending on where you live this may change as you get older – for example in England, from the age of 50, this becomes once every five years. You can also have cervical screening elsewhere, such as at a family planning or sexual health clinic, or at a private facility.

If you have never had sex, you’re at an extremely low risk of developing cervical cancer so you may choose not to have the test. If you’re not currently sexually active but have been in the past, it’s recommended that you continue to go for cervical screening. If you have had a hysterectomy, you probably won’t need to have cervical screening unless your cervix wasn’t removed. You may be invited to go for a different type of test, called a vault smear, depending on why you had a hysterectomy.

COLPOSCOPY

Services following abnormal cervical smears

The gynaecology group offer comprehensive Investigation and treatment options following the reporting of cervical smear abnormalities. Normally further investigation and treatment can be performed within a week.

HPV testing and risk assessment can also be undertaken. As yet this is not available on the NHS.

Facilities to undertake Colposcopy are available at the Nuffield Hospital. This is an investigation of the cervix with a microscope where a small biopsy of the cervix may be undertaken to confirm the abnormality. A local anaesthetic is sometimes required but the procedure normally is completed in 20 minutes and normal activities can be resumed following.

Treatment to remove precancer changes are also routinely undertaken in the outpatient suite under local anaesthetic. In some situations a general anaesthetic would be recommended or can be undertaken at patient request.

Only a minority of women will require treatment but increased surveillance with more frequent cervical smears and Colposcopy can be undertaken to minimise the likelihood of precancer progression.

The service is supervised by Mr Robert Gornall who has 20 years experience in investigation and treatment of abnormal smears. He is a member of the British Society of Cytology and Colposcopy and accredited by BUPA and Nuffield to undertake treatment.

Further information is available via the Nuffield Hospital Website (www.nuffieldhealth.com/treatments/colposcopy) or the British Society of Colposcopy and Cervical Pathology (www.bsccp.org.uk).

Mr Gornall is one of two specialist surgeons who are subspecialty accredited by the Royal College of Obstetricians and Gynaecologists to undertake the surgical management of gynaecological cancers for the population of Gloucestershire ,Herefordshire and South Worcestershire.

Further information is available via The British Gynaecological Cancer Society (www.bgcs.org.uk) or The Three Counties Cancer Network (www.the3ccancernet.org.uk) for more information and up to date guidelines.

CYTOSCOPY

A minor operation to look at the lining of the bladder using a thin telescope.

ENDOMETRIAL ABLATION

An endometrial ablation is a very effective daycase treatment for heavy periods (menorrhagia). It is when most of the womb (uterus) lining is destroyed using one of a number of techniques including electrocautery (diathermy), hot water or radiowaves.

What are the alternatives?

Other treatments for heavy periods include medicines such as the combined oral contraceptive pill or tranexamic acid.

You can also have an’ intra-uterine system’ (Mirena coil™) placed in your womb. This is a plastic T-shaped device that releases a hormone similar to progesterone and works for up to five years.

Before endometrial ablation was developed, women who had heavy periods were usually offered a hysterectomy. This is still an option, but it’s used less often because the increased risk of complications during and after a hysterectomy compared with endometrial ablation. Only women who have completed their family are suitable for an endometrial ablation and contraception is still required following the operation.

Our own groups data suggests a very high ‘satisfaction’ rate of 90%, with up to 30% of women having no more periods following an endometrial ablation.

Preparing for an endometrial ablation

We prescribe a medicine to have a month or so before your operation. This is a one-off injection which helps to thin the lining of your womb. This makes the treatment significantly more effective. Because it temporarily ‘turns off’ your ovaries it may however cause hot flushes/ night sweats. These will stop naturally in about 6 weeks or so as the medicine wears off. Bleeding with the injection is common but from a medical perspective is not a problem.

Endometrial ablation is routinely done as a day-case procedure under general anaesthetic. This means you are completely asleep for the procedure and will be able to go home the same day.

On the day of your operation we will discuss with you what will happen during and after your procedure and will ask you to sign a consent form.

What happens during endometrial ablation

There are a number of different types of endometrial ablation we use. The technique used will be tailored to you individually, taking into consideration your wombs size, shape, presence of fibroids etc.

Endometrial ablation usually takes about half an hour, including the time needed for anaesthesia and for waking up after the procedure.

For some of the techniques a thin camera called a hysteroscope is passed through your vagina and cervix so that the inside of your womb can be visualised.

Special instruments are then used to destroy or remove the womb lining using one of several methods. The main ones are listed below.

 Electrocautery (or diathermy). A small electric current is passed through a wire loop or ball-shaped sensor, which heats up (Rollerball ablation or Trans-cervical resection of endometrium)
 Heated fluid. Hot water is circulated within the womb (Hydrothermal endometrial ablation, HTA)
 Radio waves. A probe is placed inside your womb which uses radio waves (Novasure Endometrial Ablation)

What to expect afterwards

After a general anaesthetic you will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off.

You will need to wear a sanitary towel as you will have some vaginal bleeding.

You will usually be able to go home when you feel ready. You will need to arrange for someone to drive you home and you should have a friend or relative stay with you for the first 24 hours.

Recovering from endometrial ablation

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. If you’re in any doubt about driving, please contact your motor insurer so that you’re aware of their recommendations.

Most women return to usual day-to-day activities about a week post-surgery.

Vaginal bleeding / watery discharge may occur for up to a few weeks. If the discharge becomes smelly or changes in colour, or if you have pain and feel unwell, contact the hospital for advice because you may have an infection. Whilst bleeding we recommend using sanitary towels rather than tampons.

It can take a few months to see whether the operation has been successful. Most women have lighter periods after the procedure, some will stop having periods altogether. Please contact us if you start to have heavy/problematic periods again.

What are the risks?

Endometrial ablation is a commonly performed and generally safe procedure. However you need to be aware of the possible side-effects and the risk of complications.

Side-effects

Common ‘side-effects’ of an endometrial ablation are vaginal bleeding, discharge, nausea and crampy abdominal pain. These are temporary and usually relatively minor.

Complications

The vast majority of women have no major complications. Complications specific to endometrial ablation are rare but can include:

 inflammation/infection of the lining of your womb
 damage to your womb, bowel or bladder – if this is a possibility a laparoscopy is used to check and an open operation performed to repair bowel injury
 burns to your vagina or skin when heated liquids are used.
 fluid ‘overload’ (excess absorption of fluid used during some forms of ablation)

ENDOMETRIAL BIOPSY

A sample of the lining of the uterus can be taken as an outpatient to help exclude uterine cancers and other abnormalities.

ENDOMETRIOSIS

Definition

Endometriosis is a common problem affecting 10% of women. It occurs when cells which normally line the womb (endometrium) are found outside the womb. This may be anywhere in the pelvis or abdomen.

Symptoms patients commonly experience are: increasingly painful periods, pain with intercourse, pelvic pain which may come after the period and be associated with opening the bowels, irregular bleeding and sometimes difficulty conceiving.

What do we do?

During a laparoscopy the patient is anaesthetised (a general anaesthetic) and a small instrument is inserted through a 1cm incision (cut) in the umbilicus (‘tummy button’). Gas (carbon dioxide) is put into the abdomen and then a telescope (laparoscope) is inserted. This allows us to look at the outside of the womb, ovaries and the rest of the pelvis as well as the outside of the bowel. A 2nd, and sometimes 3rd or 4th additional incisions are made according to how much surgery is involved. These are usually less than 1cm long.

There are two main types of surgical treatment for endometriosis. If there are multiple tiny small spots of endometriosis they can be destroyed using electrosurgical heat treatment using a small ‘wand-like’ instrument. Deeper deposits are surgically removed from the body through the same incisions.

Although we aim to complete your surgery as a ‘key-hole’ procedure, occasionally open surgery is necessary (laparotomy). If this happens you may need another surgical procedure at a later date following further detailed explanation.

Why do we do it?

Endometriosis can only be diagnosed by a laparoscopy. Removing it at time of surgery is considered by most gynaecologists the best way to treat significant endometriosis. By removing endometriosis significant improvements in pain and irregular bleeding patterns can be made. These improvements are not necessarily permanent and repeat surgery may be required. Up to 70% of patients will have some or a lot of improvement in pain but about 25% of patients will have recurrence of symptoms and endometriosis later on. A few patients have surgery to treat endometriosis but their pain may not get better. This may be because endometriosis may not have been the cause of the pain after all.

What to expect afterwards

Some abdominal pain is normal after surgery; you will be prescribed suitable painkillers. Some patients also experience discomfort in their shoulder. This is due to the gas used during the operation and is quite common. Your body gets rid of it naturally and the pain subsides usually over a period of hours. Bruising around the cut (incision) sites may occur and will gradually disappear.

Most patients will be able to go home the same day. Some patients however, may need to stay in longer. The likelihood of this will be discussed with you before surgery.

Your gynaecologists will explain before the operation if you will need to have stitches removed or not. If this is the case they are usually removed on about the 5th day after your surgery with your practice nurse at the GP surgery. You will be told what was done before you are discharged home and given a follow-up clinic appointment.

Complications

All surgery has possible complications.

During surgery injury can occur to any of the structures inside the abdomen i.e. bowel, bladder, blood vessels and ureters (the tubes passing from the kidneys into the bladder). The chance of injury occurring is very small when the instruments are first inserted into the abdomen (about 1-4 per 1000 cases). This risk increases, however according to how severe the endometriosis is and which organs are affected (Making surgery more difficult). For all cases of endometriosis it is about 1%.

If injury to bowel or blood vessels occurs it may need to be repaired by an open operation. If severely endometriotic bowel is removed or bowel is injured a temporary colostomy may be necessary. 2% of patients with severe bowel endometriosis require a colostomy.

Adhesions (internal scar tissue) can occur after any surgery but are probably reduced following laparoscopic surgery.

Consent

Your gynaecologist will ask you to sign a consent form before your operation. This will say you understand the risks of:

- Bowel injury
- Bladder or ureteric injury
- Vascular/blood vessel injury
- Adhesions
- An open operation (laparotomy)
- Temporary colostomy

Great care is always taken to avoid these complications but they can still occur. If you do not feel able to accept these very small risks then you should choose not to have the operation done.

At home

You should make a very quick recovery from your laparoscopy. However very rarely complications become apparent after discharge home. You should seek medical advice if you have increasing pain, problems with breathing, feeling increasingly unwell or persistent vomiting.

Alternatives

Gynaecologists also use medical (hormonal) treatment for endometriosis. These work by making the deposits of endometriosis less active. This can help with pain symptoms but is not helpful for fertility problems. Some patients experience side-effects on hormone treatment. When this treatment stops and normal monthly oestrogen cycles return the endometriosis commonly flares up again. Hormonal treatment does not help symptoms due to scarring or adhesions caused by endometriosis.

HYSTEROSCOPY

Diagnostic

An outpatient or inpatient procedure allowing a quick and accurate diagnosis of the causes of abnormal vaginal bleeding. A fine telescope being passed through the cervix to allow direct visualisation of the inside of the uterus without the need for abdominal incisions.

Operative

An inpatient (General anaesthetic) procedure to remove uterine polyps, fibroids etc without the need for abdominal incisions.

HYSTERECTOMY

The Gynaecology Group are a team of highly specialised and skilled laparoscopic surgeons. Laparoscopic hysterectomy is only offered by a few gynaecologists working in the NHS and private practice but it is considered the normal practice by our consultants.

Laparoscopic sub-total hysterectomy (also called “partial” or “LASH”)

This operation involves only removing part of the uterus (leaving the cervix behind) which reduces some of the risks associated with ‘total’ hysterectomy. The procedure is performed via 3 small abdominal incisions. Following the procedure women won’t require contraception and 90% of patients will have no further menstrual bleeding .

The operation is not suitable for all patients however and your consultant can discuss this with you. Most patients are discharged home within 24 hours with less pain and usually resumption of normal activities at least 2 weeks earlierthan an abdominal (Open) hysterectomy.

Laparoscopic total hysterectomy

This operation involves removing the cervix (with or without removal of ovaries), and is usually performed with 3 or 4 small abdominal incisions (Approx 1cm). The operation is not suitable for all patients and your consultant can discuss this with you .Most patients are discharged home within 24 -48 hours with less pain and usually resumption of normal activities at least 2 weeks earlier than an abdominal (Open) hysterectomy.

Vaginal

A hysterectomy when all the procedure is undertaken through the vagina with no abdominal cuts/incisions. Only suitable for women with some degree of uterine prolapse.

Abdominal i.e open

Used when a laparoscopic approach is not suitable.

INCONTINENCE AND PROLAPSE SURGERY

If you have severe stress incontinence and other treatments haven’t been effective, your GP might recommend that you have surgery to strengthen or tighten the tissues around your urethra. As with every procedure, there are some risks associated with having surgery for bladder problems. Talk to your GP or surgeon about your surgical options and the risks that are associated with each one.

Surgical options include the following:

 Tension-free vaginal tape – for women only. During this procedure, your surgeon will make a small incision in the wall of your vagina. He or she will then insert a mesh tape into the incision, which lies between the vagina and the urethra. This supports the middle of the urethra and stops any leaks when your bladder comes under any sudden pressure. The procedure may be done under general or local anaesthetic, depending on medical factors. A general anaesthetic means you will be asleep during the procedure. Tension-free vaginal tape isn’t suitable for all women, especially if you’re considering having children.

 Sling procedures – for both men and women. A sling is a piece of human or animal tissue, or a synthetic tape that your surgeon places to support your bladder neck and urethra. This is more commonly done in women. There is a simpler type of sling implant that has been invented for men, which is usually very successful. However, it’s not suitable for men who have total incontinence or after radiotherapy.

 Burch colposuspension – for women only. Your surgeon will make a large cut in your abdomen (tummy) and lift the bladder neck upwards. He or she will then sew the lower part of the front of your vagina to a ligament behind the pubic bone to help prevent leaks. This operation requires a general anaesthetic and you will probably need to stay overnight in hospital.

 Artificial urinary sphincter – for both men and women. If your urinary sphincter doesn’t close fully, it may be possible to have it replaced with an artificial one. This is implanted around the neck of your bladder and a fluid-filled ring (called a cuff) keeps your urinary sphincter shut tight until you’re ready to pass urine. You then press a valve that is implanted under your skin to deflate the ring and allow you to urinate.

LABIOPLASTY

Labioplasty is the removal of excess labial skin from one or both labia. An increasing number of women are now requesting such simple daycase surgery. The reasons for requesting this procedure are usually either discomfort or irritation from one or other labia or simply from the appearance of a woman’s labia. It is important to say however that it is very uncommon for there to be a medical reason for asymmetrical or larger labia.

LAPAROSCOPY

A laparoscopy is a procedure used to look inside your abdomen (tummy) and examine your fallopian tubes, ovaries and womb.

A medical ‘telescope’ with a camera attached, called a laparoscope, is put into your abdomen through a small cut in your tummy button (umbilicus). The pictures from the camera are sent to a television screen and magnified, so that we can clearly see the organs inside your abdomen. Gynaecological laparoscopy can be used either to diagnose a condition or to treat a condition.

Gynaecological laparoscopy is used in many situations:

 diagnose and treat endometriosis
 diagnose and treat causes of pelvic pain
 diagnose causes of infertility i.e blocked fallopian tubes
 treat polycystic ovaries
 diagnose and remove scar tissue (adhesions)
 treat an ectopic pregnancy
 carry out female sterilisation
 remove an ovarian cyst
 remove your womb or ovaries (hysterectomy)
 treat fibroids – non-cancerous growths on or inside your womb
 remove lymph nodes for cancer treatment

What are the alternatives?

Depending on your symptoms and circumstances, there may be other investigations or treatments available. Ultrasound can also be used to diagnose some of these conditions such as fibroids and ovarian cysts. It does not treat these conditions and cannot ‘diagnose’ endometriosis.

If you need to have treatment, you may be offered a different type of surgery. For example by making a cut in the top of your vagina (vaginal hysterectomy) or an ‘open’ operation via a larger incision in your abdomen i.e abdominal hysterectomy.

We will explain the different options to you and discuss which option is best for you.

Preparing for a laparoscopy

We will explain how to prepare for your procedure. For example, if you smoke it is best if you can stop, as smoking increases your risk of getting a chest infection or wound infection and slows your recovery.

If you’re having a laparoscopy to diagnose a condition, you will usually have it done as a day-case procedure. This means you have the procedure and go home the same day. If you need to have a laparoscopy to treat a condition, you may need to stay overnight.

Laparoscopy is done under general anaesthesia ( i.e asleep during the procedure). You will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. We will clarify this for you at the preadmission clinic.

At the hospital, your nurse will do some tests such as checking your heart rate and blood pressure, and testing your urine.

On the day of the operation we will discuss with you what will happen before, during and after your procedure. It can be helpful to make a list of questions before you come in for us to answer. All patients are then asked to sign a consent form.

If you’re having a laparoscopy to diagnose your condition or because you have abdominal pain, we may go on to treat your condition during the procedure with your consent. We will discuss with you about any possible treatment before your operation.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs. You may need to have an injection of an anticlotting medicine called heparin as well as, or instead of, wearing compression stockings.

What happens during a laparoscopy?

The procedure can take 20 minutes or more, depending on what type of examination or treatment you need.

A small incision is made inside your tummy button. Carbon dioxide gas is then put into your abdomen to allow us to see all the relevant organs. Depending on what further surgery is required one, two or three small incisions are made to allow us to complete the procedure. These are in the lower part of the abdomen and are generally less than 1cm long.

If we are investigating causes of infertility, a blue dye can be injected through your cervix and into your womb and your fallopian tubes. This shows whether your fallopian tubes are blocked.

At the end of the procedure, the instruments are removed. The carbon dioxide the gas is also removed. The incisions are then closed with dissolvable stitches or surgical skin adhesive.

What to expect afterwards

You will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off.

You will usually be able to go home when you feel ready. You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours after your laparoscopy. Your nurse will give you some advice about caring for your wounds, hygiene and bathing before you go home. You may be given a date for a follow-up appointment.

Generally skin stitches can take up to 4 weeks to dissolve. If they cause skin irritation, then your GP can remove them. Surgical skin adhesive does not need to be removed and will naturally come away over a couple of weeks or so.

Recovering from a laparoscopy

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice. General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. If you’re in any doubt about driving, contact your motor insurer so that you’re aware of their recommendations.

If you have a laparoscopy to diagnose a condition you will need to rest and take it easy a few days. If you have had a more extensive laparoscopy, your recovery generally take longer. It usually takes about one to four weeks to make a full recovery from a laparoscopy, but this varies between individuals and procedures.

What are the risks?

Gynaecological laparoscopy is commonly performed and generally safe. However, you do need to be aware of the possible risk of complications.

Minor but more frequent risks include:

 bruising
 shoulder-tip pain
 wound gaping
 wound infection

Serious but rare risks include;

 damage to bowel, bladder or major blood vessels which would require immediate repair by laparoscopy or laparotomy(<1 per 1000). However, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy.
 hernia at incision site
 DVT/PE (clots in legs/lungs)

MIRENA COIL

A coil that releases a hormone within the uterus, an effective treatment for heavy periods.

MYOMECTOMY

A myomectomy is an operation to remove fibroids, leaving your womb in place. If the fibroid/s are mainly within the uterine cavity it may be removed through the cervix otherwise they can generally be removed via laparoscopic or ‘open’ surgery. Myomectomy is usually only offered to women who would like the option to become pregnant in the future. Because your womb isn’t removed there is a chance that more fibroids will grow in the future, so you may need to have further treatment.

PELVIC ULTRASOUND

An ultrasound that allows “visualisation” of the ovaries, uterus and the lining of the uterus.

Generally performed at the initial appointment.

REVERSAL OF STERILISATION

Reversal of sterilisation is requested by 1-2% of women who have previously been sterilised. This procedure is not available within the NHS. The procedure is usually undertaken laparoscopically with significantly quicker recovery and less pain and scarring than with an open operation.

Laparoscopic or open Laparosopic reversal of sterilisation paper (PDF)

STERILISATION (ESSURE 'No Cut Technique')

A permanent form of sterilisation without the need for abdominal incisions or a general anaesthetic. (A general anaesthetic can be used if requested). The procedure involves placing soft flexible micro-inserts into each fallopian tube, which over a period of 3 months block the tubes and act as a direct barrier to sperm reaching the egg.

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