Bosteels, Jan

Weyers, Steven

J. Bosteels

S. Weyers

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Outpatient treatment for uterine polyps

Ghent University Academic Bibliography

Outpatient treatment for uterine polypsA long overdue break with traditional practice, backed up by solid evidenceJan Bosteels consultant 1 2, Steven Weyers professor of gynaecology 31Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium; 2Centre for Evidence-Based Medicine, Belgian Branch of theDutch Cochrane Centre, 3000 Leuven, Belgium; 3Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, BelgiumAbnormal uterine bleeding is one of the most common reasonswhy women present to hospital gynaecology departments. Evenin developed countries such as Belgium1 a large proportion ofthese women are still being offered traditional dilatation andcurettage combined with hysteroscopy under generalanaesthesia, a costly approach that is inconvenient as it involvesan overnight stay in hospital. The dominance of traditionalinpatient dilatation and curettage is currently being challengedmost recently by Cooper and colleagues in the linked study(doi:10.1136/bmj.h1398) evaluating outpatient diagnosis andtreatment for women with uterine polyps, a common cause ofintrauterine bleeding.2During dilatation and curettage the operator is unable to seeinside the uterine cavity, and tissue is therefore removed in ablind manner. The procedure is usually done to rule outendometrial cancer, and although the diagnostic accuracy fordetecting endometrial cancer is high it is moderate for otherendometrial disease, such as uterine polyps.3 Between 20% and40% of women with abnormal uterine bleeding have polyps.Hysteroscopy allows the operator to visualise the entire uterinecavity, investigate the underlying causes of bleeding, and removetissue under direct vision.Over the past few decades advances in technology have allowedthe development of small calibre endoscopes that can be usedwithout anaesthesia in an outpatient setting. It is now feasibleto perform outpatient hysteroscopies under local anaesthesiaboth for diagnosis and for therapeutic procedures such as theremoval of endometrial polyps.4 5 Treatment can be done at themoment of diagnosis using the “see and treat” principle. Thisapproach has many potential benefits for women and for healthsystems, including faster diagnosis and treatment of abnormalbleeding and the avoidance of hospital admission. Thereforethe position of the traditional dilatation and curettage fordiagnosis and treatment of abnormal uterine bleeding hasbecome questionable.6Cooper and colleagues’ trial (Outpatient Polyp Treatment, OPT)is the first large multicentre prospective randomised controlledtrial evaluating the clinical effectiveness of outpatient versusinpatient polyp removal by hysteroscopy.2 Previous studiesreported an improvement in patients’ symptoms after removalof polyps by hysteroscopy in the outpatient versus inpatientsetting7 along with good patient tolerability, low pain scores,and faster recovery after outpatient treatment.8In the OPT trial women were recruited from 31 outpatienthysteroscopy clinics in UK National Health Service hospitals:72% of women allocated to outpatient polypectomywere treatedin “see and treat” clinics. The primary outcome was women’sown appreciation of their bleeding pattern at six months.The authors should be applauded for prioritising a patientreported outcome, and for setting a clear example for futureresearchers to follow. Many in this specialty still fail tounderstand the importance of patient reported outcomes, whichis regrettable from the viewpoint of the women who participatein trials, policy makers who use the results to inform decisions,and health systems that operate inefficiently without data onoutcomes that matter to patients.9 The COMET (Core OutcomeMeasures in Effectiveness Trials) Initiative, which supports thedevelopment, reporting, and adoption of a core outcomes set,may help in this regard.10 11The potential advantages of outpatient treatment for polypsinclude the avoidance of general anaesthesia, immediatetreatment after diagnosis, a half day’s absence from work, andnot having to rely on others for transport after the procedure.However, the limitations of performing intrauterine surgery ina conscious patient may well outweigh all these apparentbenefits. The merit of the OPT trial2 lies in clearly determiningthe limits of this trade-off. The trial shows that outpatienttreatment is non-inferior to traditional inpatient treatment foralleviating uterine bleeding.Women treated as outpatients were,however, on average twice as likely to have only partial or evenfailed polyp removals and needed further gynaecological surgerysignificantly more often than controls treated as inpatients.Although women treated as outpatients had higher mean painscores than controls, only a fewwomen in both arms found theirtreatment unacceptable. More than 90% of women in both armswould recommend either procedure to friends or relatives. Inqualitative interviews the women treated as outpatients reportedthat the pain experienced in the short term was off-set by theCorrespondence to: J Bosteels jan.bosteels@med.kuleuven.beFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2015;350:h1469 doi: 10.1136/bmj.h1469 (Published 23 March 2015) Page 1 of 2EditorialsEDITORIALSconvenience of a fast relief from their disturbed quality of lifein the longer term. Four women experienced serious adverseevents (2%); all had been treated as inpatients (2%). A fulleconomic evaluation of the OPT trial was an integral componentfrom the outset: its findings will be published at a later date.The body of evidence on the effectiveness, safety, feasibility,and acceptability of outpatient removal of polyps for treatingabnormal uterine bleeding is now on solid enough ground tojustify establishing outpatient hysteroscopy units so women canat least have a choice. Technological improvements and a desireto facilitate rapid recovery and discharge should makeoutpatient, ambulatory, or office based interventions morewidespread, in Europe and elsewhere.The uptake of outpatient hysteroscopy in Belgium is at thismoment seriously hampered by an obsolete reimbursementsystem. As women’s healthcare providers it is our responsibilityto discuss the implications of the available evidence with policymakers of healthcare systems across Europe and worldwide.For Belgian women, the findings and conclusions of the OPTtrial have come at a critical moment, as discussions have recentlybegun to encourage a break with tradition in favour of evidence.Perhaps change is finally on the way.Competing interests: We have read and understood the BMJ policy ondeclaration of interests and declare the following: none.Provenance and peer review: Commissioned; not externally peerreviewed.1 National Institute for Health and Disability Insurance. Health care department, NIHDI,Belgium.2 Cooper NAM, Clark TJ, Middleton L, Diwakar L, Smith P, Denny E, et al. Outpatient versusinpatient uterine polyp treatment for abnormal uterine bleeding: randomised controllednon-inferiority study. BMJ 2015;350:h1398.3 Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in thediagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA2002;288:1610-21.4 Marwah V, Bhandari SK. Diagnostic and interventional microhysteroscopy with use of thecoaxial bipolar electrode system. Fertil Steril 2003;79:413-7.5 Cicinelli E, Tinelli R, Loiudice L, Loiudice I, Francavilla M, Pinto V. Office polypectomywithout anesthesia with Alphascope: a randomized controlled study. J Minim InvasiveGynecol 2010;17(6 Suppl 1).6 Emanuel MH, Wamsteker K, Lammes FB. Is dilatation and curettage obsolete fordiagnosing intrauterine disorders in premenopausal patients with persistent abnormaluterine bleeding? Acta Obstet Gynecol Scand 1997;76:65-8.7 Clark TJ, Godwin J, Khan KS, Gupta JK. Ambulatory endoscopic treatment of symptomaticbenign endometrial polyps. A feasibility study. Gynecol Endosc 2002;11(2-3):91-7.8 Marsh FA, Rogerson LJ, Duffy SRG. A randomized controlled trial comparing outpatientversus day case endometrial polypectomy. BJOG 2006;113:896-901.9 Greenhalgh J, Long AF, Flynn R. The use of patient reported outcomemeasures in routineclinical practice: lack of impact or lack of theory? Soc Sci Med 2005;60:833-43.10 Williamson PR, Altman DG, Blazeby JM, ClarkeM, Gargon E. The COMET (Core OutcomeMeasures in Clinical Effectiveness Trials) initiative. Trials 2011;12(Suppl 1):A70.11 Gargon E, Gurung B, Medley N, Altman DG, Blazeby JM, Clarke M, et al. Choosingimportant health outcomes for comparative effectiveness research: a systematic review.PLoS One 2014;9:e99111.Cite this as: BMJ 2015;350:h1469© BMJ Publishing Group Ltd 2015For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2015;350:h1469 doi: 10.1136/bmj.h1469 (Published 23 March 2015) Page 2 of 2EDITORIALS

Outpatient treatment for uterine polyps : a long overdue break with traditional practice, backed up by solid evidence

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Outpatient treatment for uterine polyps A long overdue break with traditional practice, backed up by solid evidence

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Outpatient treatment for uterine polyps : a long overdue break with traditional practice, backed up by solid evidence

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