Gynaecology

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https://hdl.handle.net/20.500.14709/96

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The key features of highly effective training units in obstetrics and gynaecology
(Wiley, 2020-02-22) O'Sullivan, Marie; Newell, Sarah; Frost, Jonathan; Mountfield, Joanna; Frost, Jonathan; Medical and Dental
Key content High-quality training environments may increase job satisfaction, reduce attrition and promote excellence in education and training. Data on training are collected through the General Medical Council Survey, Training Evaluation Form and Workforce Survey. Attrition rates in obstetrics and gynaecology are high (30%) – among the highest across all specialties – and reasons for this include morale and undermining, training processes and paperwork, support and supervision, work–life balance, National Health Service environment and job satisfaction. High attrition rates affect the remaining workforce and can have a negative impact on the working environment. Learning from excellence may be more helpful than focusing on negative aspects of poor training. Learning objectives To understand the fundamental features of highly performing units. To identify contributors to poor training performance. To implement a simple structure for analysing training performance. To learn simple interventions that can improve training.
Management of Malignant Vulval Melanoma: A Retrospective Case Series and Review of the Literature
(Lippincott, Williams & Wilkins, 2020-07) Platt, Sarah; Coleridge, Sarah; Hughes, Geoff; Donkers, Hannah; Wiggans, Alison; Frost, Jonathan; Rolland, Philip; Julian, Sophia; Morrison, Jo; Pawade, Joya; Patel, Amit; Newton, Claire; Coleridge, Sarah; Frost, Jonathan; Rolland, Phil; Medical and Dental
Objectives: The aims of the study were to evaluate clinicopathologic features, management, and outcomes in vulval melanoma and to review the literature. Materials and methods: Data were collected retrospectively on patients with vulval melanoma from 2001 to 2017 in 5 gynecological oncology cancer centers (Bristol, Taunton, Truro, Plymouth, and Cheltenham). SPSS software was used for univariate and multivariate statistical analysis. Disease-specific median survival was calculated using Kaplan-Meier curves. Results: Forty-four patients with vulval melanoma were included, with a median age of 71 years. Forty-three of 44 had wide local excision with full inguinal lymphadenectomy if abnormal lymph nodes. Seven patients had sentinel lymph nodes. However, 2 patients with negative sentinel lymph nodes had distant recurrences within 16 months.On univariate analysis, presence of ulceration (p = .012), perineural invasion (p = .03), and area of lesion (p = .016) were associated with risk of recurrence but only presence of microsatellites (p = .01) was associated with risk of death.There were 31 deaths (70%): 29 (94%) of 31 from melanoma and 28 (64%) of 44 recurrences: 17 local (10 groin, 7 vulval) and 9 distant. Overall median survival was 32.5 months (95% CI, 17.8-46.5 months) and median recurrence-free survival 12.6 months (95% CI, 7.7-17.4 months). Conclusions: This retrospective multicenter study highlights the high recurrence rate and poor prognosis of vulval melanoma. Lymph node surgery did not make any difference to recurrence-free survival or overall survival. The presence of microsatellites was associated with a statistically increased risk of death.
British Gynaecological Cancer Society recommendations and guidance on patient-initiated follow-up (PIFU)
(Elsevier, 2020-04-19) Newton, Claire; Nordin, Andy; Rolland, Philip; Ind, Thomas; Larsen-Disney, Peter; Martin-Hirsch, Pierre; Beaver, Kinter; Bolton, Helen; Peevor, Richard; Fernandes, Andrea; Frost, Jonathan; Rolland, Philip; Frost, Jonathan; Medical and Dental
The National Cancer Survivorship Initiative through the National Health Service (NHS) improvement in the UK started the implementation of stratified pathways of patient-initiated follow-up (PIFU) across various tumor types. Now the initiative is continued through the Living With and Beyond Cancer program by NHS England. Evidence from non-randomized studies and systematic reviews does not demonstrate a survival advantage to the long-established practice of hospital-based follow-up regimens, traditionally over 5 years. Evidence shows that patient needs are inadequately met under the traditional follow-up programs and there is therefore an urgent need to adapt pathways to the needs of patients. The assumption that hospital-based follow-up is able to detect cancer recurrences early and hence improve patient prognosis has not been validated. A recent survey demonstrates that follow-up practice across the UK varies widely, with telephone follow-up clinics, nurse-led clinics and PIFU becoming increasingly common. There are currently no completed randomized controlled trials in PIFU in gynecological malignancies, although there is a drive towards implementing PIFU. PIFU aims to individualize patient care, based on risk of recurrence and holistic needs, and optimizing resources. The British Gynaecological Cancer Society wishes to provide the gynecological oncology community with guidance and a recommendations statement regarding the value, indications, and limitations of PIFU in endometrial, cervical, ovarian, and vulvar cancers in an effort to standardize practice and improve patient care.
Less Is More: A Narrative Review of Deciding When Surgical Intervention Should Be Withheld
(Springer, 2022-03-18) Stout, Annabel; Hamer, Jack; Sharples, Tahlia; Tahmasebi, Farshad; Sharples, Talia; Medical and Dental
Decision-making in surgery is one of the great unspoken challenges, an important but markedly challenging skill that takes a lifetime to master. The choice not to operate generally proves a significantly harder conclusion than opting for intervention. Our paper explores the influences which affect a clinician's decision to operate or not. The challenging situation where patient and clinician disagree on proposed management is also explored. Implications on management are discussed, with constructive communication techniques offered, including the recent COVID-19 pandemic.
Improving the uptake of cervical screening in pregnant and recently postnatal women: a quality improvement project
(BMJ Publishing Group, 2022-05-25) Coleridge, Sarah; Wiggans, Alison; Nelissen, Ellen; Bethune, Rob; Blackwell, Richard; Bryant, Andrew; Morrison, Jo; Wiggans, Alison; Medical and Dental
Background In 2018, cervical screening uptake was at its lowest level since screening began, particularly in those aged 25–35, coinciding with the peak incidence of cervical cancer and average age at first delivery. Problem Retrospective baseline data of pregnant women found 47.3% (n=123/260) were overdue for screening by delivery, of whom 74% (n=91/123) remained overdue by 6 months postnatal. Methods We undertook a quality improvement project from April 2018 to April 2019 to improve cervical screening uptake in pregnant and postnatal women. We mapped out the screening process and canvassed stakeholders. The main theme was inconsistency of advice received by women. From February 2018 to May 2020, we undertook a prospective audit of 10 women per week who gave birth in our maternity department, recording screening status at delivery and 6 months postnatal. Interventions included introducing evidence-based guidelines about cervical screening in pregnancy and the postnatal period, flow charts for maternity staff, multiprofessional teaching for all maternity staff and information dissemination to women (via the HANDiApp platform, a social media campaign and adapting results letters following colposcopy, highlighting dates when screening would be due). Primary care opening hours were extended for screening and women received a letter from their midwives, if they required cervical screening in pregnancy. Results Locally, the percentage of women overdue for cervical screening by 6 months postnatal improved by 8.0% during this project, compared with a 1.6% change in national screening rates in women aged 25–49. Conclusions We increased the percentage of local pregnant and postnatal women attending cervical screening by introduction of a package of information, targeted education and widening access to screening appointments.
EP336/#1095 Developing a central database and virtual biobank for rare gynaecological cancers in the UK: rango (rare neoplasms of gynaecological origin)
(Elsevier, 2022-12-01) Hall, Marcia; Mcgrane, John; Glasspool, Rosalind; Jeyneethi, Jeyarooban; Herbertson, Rebecca; Bowen, Rebecca; Saravi, Sayeh; Rolland, Phillip; Millar, Joanne; Mcdonald, Thirza; Karteris, Emmanouil; Rolland, Phillip; Medical and Dental
No abstract available
Poly(ADP-ribose) polymerase (PARP) inhibitors for the treatment of ovarian cancer
(Cochrane Collaboration, 2022-02-16) Tattersall, Abigail; Ryan, Neil; Wiggans, Alison; Rogozinska, Ewelina; Morrison, Jo; Wiggans, Alison; Medical and Dental
Background: Ovarian cancer is the sixth most common cancer in women world-wide. Epithelial ovarian cancer (EOC) is the most common; three-quarters of women present when disease has spread outside the pelvis (stage III or IV). Treatment consists of a combination of surgery and platinum-based chemotherapy. Although initial responses to chemotherapy are good, most women with advanced disease will relapse. PARP (poly (ADP-ribose) polymerase) inhibitors (PARPi), are a type of anticancer treatment that works by preventing cancer cells from repairing DNA damage, especially in those with breast cancer susceptibility gene (BRCA) variants. PARPi offer a different mechanism of anticancer treatment from conventional chemotherapy. Objectives: To determine the benefits and risks of poly (ADP-ribose) polymerase) inhibitors (PARPi) for the treatment of epithelial ovarian cancer (EOC). Search methods: We identified randomised controlled trials (RCTs) by searching the Cochrane Central Register of Controlled Trials (Central 2020, Issue 10), Cochrane Gynaecological Cancer Group Trial Register, MEDLINE (1990 to October 2020), Embase (1990 to October 2020), ongoing trials on www.controlled-trials.com/rct, www.clinicaltrials.gov, www.cancer.gov/clinicaltrials, the National Research Register (NRR), FDA database and pharmaceutical industry biomedical literature. Selection criteria: We included trials that randomised women with EOC to PARPi with no treatment, or PARPi versus conventional chemotherapy, or PARPi together with conventional chemotherapy versus conventional chemotherapy alone. Data collection and analysis: We used standard Cochrane methodology. Two review authors independently assessed whether studies met the inclusion criteria. We contacted investigators for additional data. Outcomes included overall survival (OS), objective response rate (ORR), quality of life (QoL) and rate of adverse events. Main results: We included 15 studies (6109 participants); four (3070 participants) with newly-diagnosed, advanced EOC and 11 (3039 participants) with recurrent EOC. The studies varied in types of comparisons and evaluated PARPi. Eight studies were judged as at low risk of bias in most of the domains. Quality of life data were generally poorly reported. Below we present six key comparisons. The majority of participants had BRCA mutations, either in their tumour (sBRCAmut) and/or germline (gBRCAmut), or homologous recombination deficiencies (HRD) in their tumours. Newly diagnosed EOC Overall, four studies evaluated the effect of PARPi in newly-diagnosed, advanced EOC. Two compared PARPi with chemotherapy and chemotherapy alone. OS data were not reported. The combination of PARPi with chemotherapy may have little to no difference in progression-free survival (PFS) (two studies, 1564 participants; hazard ratio (HR) 0.82, 95% confidence interval (CI 0).49 to 1.38; very low-certainty evidence)(no evidence of disease progression at 12 months' 63% with PARPi versus 69% for placebo). PARPi with chemotherapy likely increases any severe adverse event (SevAE) (grade 3 or higher) slightly (45%) compared with chemotherapy alone (51%) (two studies, 1549 participants, risk ratio (RR) 1.13, 95% CI 1.07 to 1.20; high-certainty evidence). PARPi combined with chemotherapy compared with chemotherapy alone likely results in little to no difference in the QoL (one study; 744 participants, MD 1.56 95% CI -0.42 to 3.54; moderate-certainty evidence). Two studies compared PARPi monotherapy with placebo as maintenance after first-line chemotherapy in newly diagnosed EOC. PARPi probably results in little to no difference in OS (two studies, 1124 participants; HR 0.81, 95%CI 0.59 to 1.13; moderate-certainty evidence) (alive at 12 months 68% with PARPi versus 62% for placebo). However, PARPi may increase PFS (two studies, 1124 participants; HR 0.42, 95% CI 0.19 to 0.92; low-certainty evidence) (no evidence of disease progression at 12 months' 55% with PARPi versus 24% for placebo). There may be an increase in the risk of experiencing any SevAE (grade 3 or higher) with PARPi (54%) compared with placebo (19%)(two studies, 1118 participants, RR 2.87, 95% CI 1.65 to 4.99; very low-certainty evidence), but the evidence is very uncertain. There is probably a slight reduction in QoL with PARPi, although this may not be clinically significant (one study, 362 participants; MD -3.00, 95%CI -4.48 to -1.52; moderate-certainty evidence). Recurrent, platinum-sensitive EOC Overall, 10 studies evaluated the effect of PARPi in recurrent platinum-sensitive EOC. Three studies compared PARPi monotherapy with chemotherapy alone. PARPi may result in little to no difference in OS (two studies, 331 participants; HR 0.95, 95%CI 0.62 to 1.47; low-certainty evidence) (percentage alive at 36 months 18% with PARPi versus 17% for placebo). Evidence is very uncertain about the effect of PARPi on PFS (three studies, 739 participants; HR 0.88, 95%CI 0.56 to 1.38; very low-certainty evidence)(no evidence of disease progression at 12 months 26% with PARPi versus 22% for placebo). There may be little to no difference in rates of any SevAE (grade 3 or higher) with PARPi (50%) than chemotherapy alone (47%) (one study, 254 participants; RR 1.06, 95%CI 0.80 to 1.39; low-certainty evidence). Four studies compared PARPi monotherapy as maintenance with placebo. PARPi may result in little to no difference in OS (two studies, 560 participants; HR 0.88, 95%CI 0.65 to 1.20; moderate-certainty evidence)(percentage alive at 36 months 21% with PARPi versus 17% for placebo). However, evidence suggests that PARPi as maintenance therapy results in a large PFS (four studies, 1677 participants; HR 0.34, 95% CI 0.28 to 0.42; high-certainty evidence)(no evidence of disease progression at 12 months 37% with PARPi versus 5.5% for placebo). PARPi maintenance therapy may result in a large increase in any SevAE (51%) (grade 3 or higher) than placebo (19%)(four studies, 1665 participants, RR 2.62, 95%CI 1.85 to 3.72; low-certainty evidence). PARPi compared with chemotherapy may result in little or no change in QoL (one study, 229 participants, MD 1.20, 95%CI -1.75 to 4.16; low-certainty evidence). Recurrent, platinum-resistant EOC Two studies compared PARPi with chemotherapy. The certainty of evidence in both studies was graded as very low. Overall, there was minimal information on the QoL and adverse events. Authors' conclusions: PARPi maintenance treatment after chemotherapy may improve PFS in women with newly-diagnosed and recurrent platinum-sensitive EOC; there may be little to no effect on OS, although OS data are immature. Overall, this is likely at the expense of an increase in SevAE. It is disappointing that data on quality of life outcomes are relatively sparse. More research is needed to determine whether PARPi have a role to play in platinum-resistant disease.
Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial
(Springer, 2021-08-23) Izett-Kay, Matthew; Rahmanou, Philip; Cartwright, Rufus; Price, Natalia; Jackson, Simon; Rahmanou, Philip; Medical and Dental
Introduction and hypothesis: Laparoscopic mesh sacrohysteropexy offers a uterine-sparing alternative to vaginal hysterectomy with apical suspension, although randomised comparative data are lacking. This study was aimed at comparing the long-term efficacy of laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse. Methods: A randomised controlled trial comparing laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse was performed, with a minimum follow-up of 7 years. The primary outcome was reoperation for apical prolapse. Secondary outcomes included patient-reported mesh complications, Pelvic Organ Prolapse Quantification, Patient Global Impression of Improvement in prolapse symptoms and the International Consultation on Incontinence Questionnaire Vaginal Symptoms, Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and PISQ-12 questionnaires. Results: A total of 101 women were randomised and 62 women attended for follow-up at a mean of 100 months postoperatively (range 84-119 months). None reported a mesh-associated complication. The risk of reoperation for apical prolapse was 17.2% following vaginal hysterectomy (VH) and 6.1% following laparoscopic mesh sacrohysteropexy (LSH; relative risk 0.34, 95% CI 0.07-1.68, p = 0.17). Laparoscopic sacrohysteropexy was associated with a statistically significantly higher apical suspension (POP-Q point C -5 vs -4.25, p = 0.02) and longer total vaginal length (9 cm vs 6 cm, p < 0.001). There was no difference in the change in ICIQ-VS scores between the two groups (ICIQ-VS change -22 vs -25, p = 0.59). Conclusion: Laparoscopic sacrohysteropexy and vaginal hysterectomy with apical suspension have comparable reoperation rates and subjective outcomes. Potential advantages of laparoscopic sacrohysteropexy include a lower risk of apical reoperation, greater apical support and increased total vaginal length.
Comparative Efficacy of Metformin and Combined Oral Contraceptives in the Management of Adolescent Polycystic Ovary Syndrome: A Systematic Review of Randomized Controlled Trials
(Springer, 2025-05-10) Mandvia, Aqsa; George, Rebecca; Kumari, Komal; Kumari, Katee; Sabbagh, Leen; Bhullar, Amritveer; Ismail, Danyah Mohammad; Kolanu, Nikhil Deep; Ali, Amir; Mandvia, Aqsa; Medical and Dental
This systematic review explores the comparative efficacy of metformin, combined oral contraceptives (COCs), and their combination in the management of polycystic ovary syndrome (PCOS) among adolescent females. A comprehensive literature search was conducted across PubMed, Scopus, and Cochrane CENTRAL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, yielding 645 records, of which seven randomized controlled trials (RCTs) met the inclusion criteria. The included studies varied in design, population size, and outcome focus but consistently evaluated metabolic, hormonal, and reproductive endpoints. Results indicated that, while COCs were effective in reducing hyperandrogenic symptoms and regulating menstrual cycles, they were often associated with adverse metabolic effects, such as increased hepatic enzymes and insulin resistance. In contrast, insulin-sensitizing agents, particularly in combination regimens such as SPIOMET (spironolactone, pioglitazone, and metformin combination), showed superior outcomes in improving ovulation rates, insulin sensitivity, and body composition, with fewer metabolic side effects. Combination therapy with metformin and COCs also demonstrated a balanced improvement in both reproductive and metabolic profiles. The overall quality of included studies was rated as having some concerns due to variability in study design and reporting. Despite these limitations, the evidence supports a more individualized and metabolically focused approach to managing adolescent PCOS, emphasizing the benefits of early intervention with insulin-sensitizing therapies.
Mismatch in testing: a retrospective analysis of mismatch repair testing in endometrial cancer and Lynch syndrome diagnosis in multiple specialist centres in the UK and Ireland (March 2022–March 2023)
(BMJ Publishing Group, 2025-06-09) Ryan, Neil; Lennie, Kane; Naskretski, Adam; Anderson, Craig; Mihaita, Lorena; Abeysuriya, Sanduni; Ashworth, Maria; Cullimore, Victoria; Dobson, Lucy; Graham, Nathan; Graham, Radha; Haran, Shaun; Holwek, Zuzanna; Hunt, Ashton; Johnston, Ben; Karkia, Rebecca; Kouklidis, Georgios; Leung, Elaine; McCormick, Aiste; McMiullan, Josh; Mohan, Alison; Montgomery, Alison; Newton, Claire; Nikolopoulos, Manolis; Norden, Catriona; Nott, Charlotte; Owens, Gemma; Rolland, Phillip; Ricketts, Sammuel; Sivalingam, Vanitha; Smith, David; Tesfai, Freweini; Tookman, Laura; Whacha, Chenai; Sanderson, Peter; Leung, Elaine; Medical and Dental
Objectives To assess the implementation of Lynch syndrome testing in endometrial cancer (EC) across the UK and Ireland, identify diagnostic gaps and evaluate adherence to the National Institute for Health and Care Excellence (NICE) guidelines recommending routine mismatch repair (MMR) deficiency testing. Methods and analysis A multi-centre, cross-sectional retrospective study conducted in line with STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. Secondary care cancer centres across the UK and Republic of Ireland were identified with support from the ARGO (Audit and Research in Gynaecological Oncology) Collaborative and invited to complete a bespoke data collection tool. Results Data from 2716 histologically confirmed EC cases treated between March 2022 and March 2023 were collected. After excluding misdiagnosed and inconsistent cases, 2549 were analysed. The cohort had a mean age of 66.3 years and a mean body mass index of 33.43 kg/m²; 69.3% had endometrioid EC histology. MMR testing was performed in 91% of cases, with 27.6% classified as MMR deficient, mainly due to MLH1/PMS2 loss (77.4%). Of the 510 cases requiring hypermethylation analysis, results were missing for 62. Of the 181 participants eligible for genetic counselling, 64% were referred and 48% underwent germline testing, identifying 19 new Lynch syndrome cases. MMR-deficient tumours were diagnosed at earlier stages and lower grades compared with MMR-proficient tumours. Conclusions While tumour based MMR testing is widely performed, diagnostic attrition significantly impairs the pathway to definitive Lynch syndrome diagnosis. Addressing barriers to genetic counselling and germline testing is crucial for improving patient outcomes and the cost-effectiveness of Lynch syndrome screening.
Workload, Availability of Diagnostic Tools, and Treatment Options for Urinary Incontinence and Other Pelvic Floor Disorders in Women: An Online Survey on Practice and Challenges Faced by Providers of Urogynaecological Healthcare in Ten African Countries
(Springer Nature, 2025-02-10) Muriithi, Francis; Brandt, Corlia; Muavha, Dakalo; Byamukama, Onesmus; Bagala, John; Vij, Monika; Muriithi, Francis; Medical and Dental
Introduction and hypothesis: Pelvic dysfunction, including urinary incontinence, significantly impacts the quality of life of affected women, diminishing their freedom and dignity. In many African countries, challenges such as limited funding, competing health priorities and cultural stigma on pelvic health further restrict access to care. This information gap may hinder the effective design and implementation of interventions aimed at improving urogynaecological healthcare delivery. The objective of this study was to estimate the urogynaecological workload, the availability of tools to investigate and treat urinary incontinence in women, and to understand the challenges faced by providers of urogynaecological healthcare in 10 African countries. Methods: A cross-sectional online survey of urogynaecological service providers. Results: Forty-seven responses were analysed, revealing that 40% of gynaecological consultations addressed urogynaecological concerns, with 60% related to prolapse, 40% to bladder issues, 7.5% to bowel problems and 5% to sexual dysfunction. Among bladder issues, 35% involved obstetric fistulas, 22.5% stress urinary incontinence, 12.5% mixed urinary incontinence and 10% overactive bladder. Identified resource gaps included insufficient numbers and training of providers, limited access to diagnostic tools such as urodynamics equipment, and inadequate availability of neuromodulation and advanced surgical options. Key challenges in healthcare delivery were lack of patient awareness and inadequate funding, especially in public-sector facilities. Conclusion: Gaps exist in the access and delivery of urogynaecological healthcare to patients with pelvic floor dysfunction in sub-Saharan Africa. Specific areas of focus should include patient education and capacity building, including human resources, access to affordable screening and diagnostic tools and technologies, and investment in affordable management options.
Mixed methods study of attitudes on location of gynaecological oncology outpatient care: a patient and healthcare professional questionnaire
(2024-01-17) Newhouse, Rebecca; Cullimore, Victoria; Hotton, Emily; Maxwell, Hilary; Jones, Eleanor; Morrison, Jo; Newhouse, Rebecca; Medical and Dental
Objective: Gynaecological oncology place of care is often based on evolution of services, along historical professional boundaries, rather than user needs or preferences. We aimed to assess existing evidence, gather views of patients in the UK on their preferred place of outpatient care for gynaecological malignancies and evaluate alignment with preferences of healthcare professionals (HCP). Methods: We performed a mixed methods study, including a scoping review, a patient survey and a healthcare practitioner questionnaire. We collected quantitative and qualitative data, performing content analysis to determine current practice and impact on patients. Results: No studies were identified in our scoping review. We received responses from 159 patients and 54 gynaecological oncology HCPs. There was a strong preference for a dedicated gynaecological oncology setting (89% somewhat or very happy) (p<0.0001). Fifty-three percent of patients were somewhat or very unhappy to have care colocated with general obstetrics and gynaecology services. Specifically, two key themes were identified through content analysis of qualitative data from patients: 'environment and getting this right is vital'; and 'our cancer should be the priority'. HCPs underestimated the strong patient preference to be seen in dedicated units. Of those who see patients within general obstetrics and gynaecology, only 50% said patients were seen at separate times/locations from obstetric patients. Conclusion: This study demonstrates the significant impact of place of care on gynaecological oncology patients, which may be underestimated by HCPs.

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