ACCESS TO RATIONAL TREATMENT FOR GYNAECOLOGICAL MORBIDITIES
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- Title
- ACCESS TO RATIONAL TREATMENT FOR GYNAECOLOGICAL MORBIDITIES
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RF_WH_.11_13_SUDHA
29-01-2024
Welcome
Gl IDELIXES TO PREVENT
UNNECESSARY
HYSTERECTOMIES
MINISTRY OF HEALTH & FAMILY WELFARE
1
29-01-2024
SAGE
Supporting Access for Gynaecological assessment for rural women using E- Health & Ai
Data Driven Mentorship
Program for Reduction of
Unnecessary Hysterectomies
2
29-01-2024
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One third members are women
Gram Panchayath
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30,110
ABDUL NAZIR SAB STATE INSTITUTE OF RURAL DEVELOPMENT
AND PANCHAYAT RAJ
6
29-01-2024
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lc AUB -Metrorrhagia, 01 igomenorrhoea, Amenorrhoea- irregular bleeding in high
risk group (obese, hypertensive,diabetic, family history of endometrial /cervical
cancers), AUB in women > 40 years of age, OR Persistent dysmenorrhea
/1
GRAAMA PANCHAYATH
AROGYA AMRUTHA ABHIYAANA
A convergenceinitiative to strengthen Gram
Panchayat leadership to ensure the health
of last mile communities
” USAID
OH
KHPT
Key components of a communication strategy to address unnecessary
hysterectomy
6 Post hysterectomy follow up of woman who had Hysterectomy before 45 years
of age
Hub & Spoke
.NODE
NODE
NODE
NfX
7
29-01-2024
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29-01-2024
tyus Wan Bharat
L Arogya
MRrF
yuToT atsft ijfaf tFcirjazi
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Speciality
SI. no.
Procedure code
Rate;
Procedure name
code
12B.S4.00010 : Vaginal hysterectomy with anterior and
S4
161
2B.S4.000IC
S4
165
Innstennr rnlnnnerinenrrhanhv
12B $4.00023 : Laparoscopic hysterectomy (TLH)
2B.S4.00023
PO3t-Op
Pre-op
16000
Relevant Hematologxal
linve'itinatinn-. f liniral nntir
20900
I Ultra:onography. X Ray. EC6, LH.RR,
HPR.OT note;
pBS.PPBS. T3.T4.THS
O’ Note; and FPE
Ultrasonography, X Ray. ECG. LH.RFT
182
’ 1500
2B $4.17016 : Lap. A::i:ted Vaginal Hysterectomy 'LAVH)
2B $4.17016
$4
^BS.PPBS, T3.T4,’HS/ Endometrial
HPR.OT note:
Biopiy.'Cervical biopsy
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29-01-2024
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No. of Hysterectomy cases conducted < 40 years
z 1 ire Kolai<
Ha-saii
Mandya
/
agftg
How do we pick sites for mentoring?
• Total number of hysterectomy in the site past 3 years = 150
• Total number of hysterectomy in less than 40 years since past 3 years
= 10
• 10*100/150 =1000/150 = 6.6%
10
29-01-2024
Site
Total Hyst
Hyst <40
1
200
30
2
3
400
50
10
9
4
30
7
5
600
50
8%
6
250
15
6%
7
15
8
100
350
65
Total
1980
201
3%
10%
Sector ABARK Empanelled -
Uulbafsa
Bijapur
%
538
Yadpr
Raiclutr
Hclgatmi
Health
Koppa!
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Insurance
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11
29-01-2024
O
O
o
o
o
o
o
o
o
N«wT»b
Age
Parity
Occupation
Indication of hysterectomy
Previous medical/surgical history
Hysterectomy route:
■ Abdominal
Vaginal
■ Laparoscopic
Any other surgery done along with hysterectomy:
Past treatment history:
HPE:
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12
29-01-2024
District Hysterectomy Monitoring Committees
A District Hysterectomy Monitoring Committee must be set up in each district
to enable effective monitoring. The committee must be set up under the chairpersonship
of District CMC. NCD Nodal, District RCH Nodal Officers / Maternal Health Nodal Officers,
other key government personnel at the district level, representatives from FOGSI (both
public and private sector), representatives from development partners etc. The
monitoring committee is expected to:
'.o’
'A
F PUBLIC L
1 HEALTH A
Bharat
/ L. Arogya
^rnataka
^yusjht
ejdjaert21
i yiRci
VIUTcT atoft U?cT JJcTGJSZJ d I viol I
Put a stop to unnecessary
y^ysterector&ies
13
29-01-2024
GUIDELINES TO PREVENT
UNNECESSARY HYSTERECTOMIES
DR RUPALI ROY, ADG
DTE.GHS, MOHFW,
NIRMAN BHAWAN, DELHI
Background
• Hysterectomy emerged as a health concern since 2013
• Low age at hysterectomy (<40 years) emerged in NFHS-4
• Some states with high prevalence, up to 1 in 5 women by age 50
I
• MoHFW consultation in 2019 with experts to develop:
• Clinical and population-level guidelines on hysterectomy
• Information on treatment of gynecological morbidity
• Strategies for community awareness
• 2023 Supreme Court response to PIL mandated the implementation
of MoHFW guidelines.
• As per NFHS 5 (2019-21), Percentage of women who have had a
hysterectomy in Karnataka is 3.4
1
29-01-2024
Purpose of the guidelines
• Guidance to public health programme managers on measures to address
unnecessary hysterectomy at the facility level
• Strategies for monitoring and community awareness generation activities
• Clinical guidelines on common conditions that have emerged as indications for
hysterectomy
• AUB/DUB, lower abdominal pain, discharge, uterine prolapse, abnormal cervix etc.
• Audit and data collection forms
Programmatic Guidance
Provides guidance to Programme Managers on:
i)
Interventions at primary, secondary and tertiary level
2)
Capacity stre^thenir^^secondary|and primary level s^vice providers (Medical
services
3)
Referrals and Continuum of Care, starting with HWCs
4)
Awareness Generation
5)
Ensuring appropriate use of health insurance/PM-JAY
2
29-01-2024
Monitoring & Evaluation
Guidelines mandate establishment of3-tiered monitoring structure
National Hysterectomy Monitoring Committee
Chairperson
AS&MD, NHM
Members
Officials from Directorate, NCD, ICIV1R, MH
Role
• Meet once in every six months and review state level data
• Arrange necessary trainings and sensitization sessions for both public and private sector
• Review the landscape and take necessary policy decisions as required
• Sub-committees on I EC, alternative treatments and clinical protocols
3
29-01-2024
State Hysterectomy Monitoring Committee
Chairperson
Principal Secretary
Members
• State level Director Public Health - Nodal Officer
• NCD State program officer
• RCH/FW/MH programme officers
• FOGSI members(public and private sector)
• Development partners
Role
• Meet once in every six months and review district level data
• Arrange necessary trainings and sensitization sessions for both public and private sector
professionals and district officials.
District Hysterectomy Monitoring
Committee
Chairperson
District CMO
Members
• NCD Nodal Officer
• District RCH Nodal Officers / Maternal Health Nodal Officers
• FOGSI members (public and private sector)
• Development partners
Role
•
Ensure public and private sectors submit a monthly line list of all women who underwent hysterectomy
•
Monthly Audit of cases with following indications:
• Hysterectomy with/ without BSO in women <35 yrs. of age
•
•
•
Hysterectomy with BSO in women < 40 yrs. of age
All cases where no indication for doing the procedure is mentioned in the records
•
All cases where no records of treatment priorto hysterectomy (in papers or in history) are available
•
Discrepancy between mentioned indication and HRE report
•
Any severe morbidity/mortality due to hysterectomy
Arrange necessary trainings and sensitization sessions for both public and private sector professionals
4
29-01-2024
State-level Data Collection
Details of Hysterectomy done in one month in State's/UT's
Name of the State's/UT's.
Month.
.Year.
Route Indicatio
of
n for
hystere hysterect
Surgery
ctomy omy DUB Whether Any Histopht Durati Treatment
Name and
ID No.
perform
Open /AUB/
ovaries hystere hology on of taken prior
Any
address of
/Serial
ed by Obstet abdomi Fibroid/
were
ctomy Report/illness to surgery/ Pre- comm
facility where
no/Cen
ric
nal/ Prolapse removed related Specime prior Duration ofexistin ents/R
Town/ surgery was Public Age at Gynaec
tral
facility/ time of ologist / history laparosc/Maligna .If yes compile
n
to treatment/ gCo emark
Registr
city/
done
district (Registration Private hystere General - Para/ opic/ ncy/Othe One/
ations Remove surgerHormonal/L Morbid sif
ation
facility ctomy surgeon Live vaginal
rs
Both
(list)
d
y
NG/others ities
any
No)
S.No. No. Age /Tehsil
Clinical protocols
Guidelines detail out treatment modalities available for common indications of
hysterectomy:
• Abnormal Uterine Bleeding/ Dysfunctional Uterine Bleeding
• Uterocervicovaginal Prolapse
• Vaginal Discharge
• Pelvic Inflammatory Disease (PID)
• Abnormal Cervix
^This is a developing area, in partnership with gynaecologists
5
29-01-2024
Awareness Generation
• Can use existing platforms such as Village Health Sanitation and Nutrition Committees,
Women's Self-Help Groups, Mahila Arogya Samities, and Rogi Kalyan Samities at PHC,
CHC and district hospitals
• Focus on removing myths and misconceptions in the community and raising awareness
on menstrual hygiene practices
• Emphasis: hysterectomy is not the first choice of treatment for most conditions
Current Status
• States in process of forming Committees
• Sub-committee on IEC and AlternativeTreatments at national level
• Available data will be analysed by ICMR in coming months
• NFHS and LASI continue to include hysterectomy at population level
• Consultations for feedback on guidelines
6
29-01-2024
THANKYOU
7
29-01-2024
r
Use of
gynaecological
surgery in
Karnataka:
R.
Trends from
NFHS
National patterns of hysterectomy (40-49,50+)
Prevalence of hysterectomy among women aged 40-49 (NFHS-5)
Prevalence of hysterectomy among women aged 50 and above (LASI)
, _Prevalence
Q 0 0-99
I 110.0-19.9
LJ 20 0 and abovo
J
>
f
L
\
Karnataka
14.9%
Karnataka
8.9%
•
J
*
Source: NFHS-5 (2019-21)
__ Prevalence
□ 00 8 9
| 10 019 9
M 20 0 S above
Fl No data
f
*
Source: LASI (2017-18)
1
29-01-2024
Place of hysterectomy, by wealth quintile of households
■ Public facilities
STH QUINTILE
< Private facilities
70.7
29.3
4TH QUINTILE
41.8
58.2
3RD QUINTILE
41.7
58.3
2ND QUINTILE
1ST QUINTILE
51.7
48.3
42.6
57.4
PROPORTION
Source: NFHS-5 (2019-21)
Hysterectomy and NCDs
6
29-01-2024
Hysterectomy and NCDs later in life
Findings from the LASI study, 2017
A nationally representative sample of women, aged 45 and up in India:
A woman with hysterectomy had....
1.5 times higher odds of hypertension
1.7 times higher odds of diabetes
1.5 times higher odds of bones/ joint diseases
when compared with women without a hysterectomy
Adjusted for age, education, marital status, wealth status, caste, religion, urban/rural location, BMI category.
C-section and Sterilisation
7
29-01-2024
National Patterns
% c-secton delve'v
30%.
20 to 30%
10 to 20%
•10%
% Fctralc St«««Hoii
Z 30k>M%
= mv*
ZJ HotUU
Female Sterilisation
C-section
Source: NFHS-5 (2019-21)
C-sections* and Female Sterilisation
Female Sterilisation
C-section
India
21.5
India
37.9
Karnataka
31.5
Karnataka
57.4
Urban
35.2
Urban
55.2
Rural
29.4
Rural
SM
C'secnons
female ste'ilsaiton
■ 521
*: all births in last 5 years, WHS 5 (2019-21)
Source: NFHS-5 (2019-21)
8
29-01-2024
Modern contraceptive method mix, married women 15-49
Female Sterilization
Male Condom
mCPR
Karnataka
68.2
Standard Days Method (SDM)
■ Other Modern Method
■ Emergency Contraception
mCPR
India
56.4
Method
India
Karnataka
Pill
5.1
2.1
IUD
2.1
2.9
Injections
0.6
0.5
Diaphragm
0
0.0
Male Condom
9.5
4.1
Female Sterilization
37.9
57.4
Male Sterilization
0.3
0.0
Lactational Amenorrhea (Lam)
0.7
0.7
Female Condom
0
0.2
Foam Or Jelly
0
0.0
Emergency Contraception
0.1
0.1
Ki Foam Or Jelly
■ Female Condom
H Lactational Amenorrhea (Lam)
■ Male Sterilization
Diaphragm
Injections
IUD
M Pill
I.
o mCPR
India
I
Karnataka
Other Modern Method
0
0.0
Standard Days Method (SDM)
0.2
0.1
mCPR
56.4
68.2
Source: NFHS-5 (2019-21)
Thank you
Sapna.i.desai@gmail.com
9
Public Health & Women’s Health
Perspectives
Roles & responsibilities
as health practitioners
18th December 2023
Roundtable on ‘Access to Rational Care for
Gynaecological morbidities & Prevention of Unnecessary
Hysterectomies
Dr. Thelma Narayan
SOCHARA- Bangalore
The Essence of Public Health
■ PH aims to protect, promote & restore
population health through organised
systematic efforts ie it’s societal in scope w
■ Community health influences PH through
‘communitisation’ of the health system
■ PH utilises government action, & is
influenced by power of the state & how it is
exercised. Tensions can arise with people
■ & may exist between clinical (individual) care
and PH programs
2
1
Public Health Ethics
■ Tries to bring greatest benefit to health &
well being of populations, while
attempting to minimise disruption of
individual rights and autonomy
■ process to clarify, prioritise, and justify
possible courses of public health action
based on ethical principles, values and
beliefs of stakeholders, and scientific and
other information
Women’s Health
Hey! There is
more to me than
just my womb!
DIGNITY OF WOMEN AS
INDIVIDUAL PERSONS
EQUAL STATUS FOR WOMEN
IN SOCIETY
2
A framework for Women’s Health
■ Women’s Right to Health and Quality Health
Care
■ State obligations to promote & protect
women’s health rights
■ Medical ethics & rights of women as patients
■ Laws & policies related to health
Issues affecting Women’s Health
■ Violence against women: a public health &
human rights issue. This includes
unnecessary surgery
■ Social determinants of health (SDH)
underlying unnecessary hysterectomies
■ Access to care for women with special
needs
3
FA CTORS AFFECTING
WOMEN’S HEAL TH
I
r. > i \rf<
F \' V
7
Policy Overview
the paradox
and the crisis
4
Realizing the Universal Human
Right to Health
Address underlying societal determinants of
health, illness & health care provided
Work related stress for women
Financial pressures
Inadequate understanding of consequences of
procedures
Poor governance of the health system
Accountability mechanisms
Inter - Connected Rights
Social
Economic
Political
Civil
Cultural
Rights
The Right to
Health and
Health Care
Universal Health
Care
Universal Social
Protection
5
Human Rights Commitments
UDHR (Universal Declaration of HR) 1948
CEDAW (Convention on the Elimination of
All forms of Discriminations Against
Women) 1979
CRC (Convention on Rights of the Child);
UN Resolution on Child, Early and Forced
Marriage, 2013
DEVELOPMENTS - IN THE
LAST TWO DECADES
Signs of Hope
CMC
6
Karnataka Task Force on Health and Family Welfare 2001
Recommendations for Human Resource Development in
Health
KARNATAKA
TOWARDS
EQUITY. QUAIITY AND INTEGRITY IN HEALTH
5’
i2
I
a
8
8
I
5
FINAL REPORT
§
01
TNI TASH fORCA OM KtAITH a FAMinr WKIfAMI
GOVIRNMINT OF KARNATAKA
AIBfMl70ai
Karnataka State Integrated Health Policy 2003
2
Department of Health & Family Welfare
Karnataka State Integrated Health Policy
IS •
-
7
Health Policy concerns
Govt, of Karnataka 2004
WOMEN
AS A WHOLE PERSON
ENTIRE LIFE - life cycle approach
EMPOWERMENT
COMMUNITY DEVELOPMENT
ENHANCE ACCESS TO HEALTH CARE
MALE PARTICIPATION
GENDER SENSITISATION OF THE HEALTH SYSTEM
15
GENERAL OBJECTIVES OF THE
POLICY
IMPROVE WOMEN’S HEALTH STATUS
IMPROVE WOMEN’S ACCESS TO
QUALITY HEALTH CARE
MAKE HEALTH SERVICES GENDER
SENSITIVE & WOMEN FRIENDLY
16
8
Women’s voices for women’s health
We are Women]
And we form half
We do two third
of its work!
of humanity
And wc own only
one-hundredtli of
its property.
But we earn only
one-tenth of its
income
THE CHALLENGES
AHEAD
9
I
CAN WE OFFER WOMEN
A BETTER WORLD?
WHERE WE ARE
HEARD ?
WHERE WE
MATTER?
TOGETHER,
LET US DEVELOP A
DEEPER
UNDERSTANDING
REGARDING WOMEN’S
HEALTH
19
Hey! There is
more to me than
just my womb!
DIGNITY
PERSONHOOD
SELF REFLECTION
10
29-01-2024
A 9KW5CW*
1*
PRESERVE THE UTERUS-AWARENESS AND
IMPROVING GYNAECOLOGICAL CARE AND
PREVENTION OF UNNECESSARY
HYSTERECTOMIES
Dr Shashikala Karanth
Professor and HOD
SJMCH
<- MCAUMOUt
I*
w.
• Health of women is paramount to ensure the health of communities and the nation
• “Awareness is the key to initiate informed decision making when it comes to women’s
health
1
29-01-2024
• Preserve the uterus Campaign launched nationwide 20th April 2022 pharmaceutical company in Partnership with FOGS1 and 1 he Integrated Health
and well being Council (IHW)
• Aim to Raise awareness among women
-sensitize and Educate health care practitioners through Knowledge sharing and
upskilling workshops across the country via virtual and physical meetings
-Help Women to understand alternative treatment for minor gynecological issues
KCUACOTME
> PRESERVE
k UTERUSj
REASON FOR UNNECESSARY HYSTERECTOMIES
1°
• Indian women, especially those living in small towns and villages, have poor knowledge
of their reproductive health
• Fear of cancer
• Abnormal uterine bleeding
• Public health insurance
• Relate all somatic symptoms to uterus
• RMP/GP-Counsel the patient for hysterectomies
2
29-01-2024
: PRESERVE
k UTERUS,
REASON FOR UNNECESSARY HYSTERECTOMIES
CONTD
• Lack of integrated broadminded approach among Doctors
• White discharge PV
• Attitude towards women's health
• Taboo• Lack of support from family member for follow up
MOST COMMON INDICATION FOR HYSTERERCTOMY
IS THE MOST COMMON SURGERY IN WOMEN AFTER CAESAREAN DELIVERY IN INDIA
THE MOST COMMON INDICATIONS FOR HYSTERECTOMY IN INDIA ARE:
FIBROIDS(45%)
HMB(3I%)
CERVICAL DYSPLASIA (3%)
PELVIC INFLAMMATORY DISEASE AND
ENDOMETRIAL HYPERPLASIA
PROLAPSED UTERUS AND CERVICAL CANCER ARE OTHER CONDITIONS THAT MAY NECESSITATE
HYSTERECTOMY
1
29-01-2024
ALTERNATIVE TREATMENT
q*aT«it
• healthcare practitioners actively favoring more conservative approaches
• Alternative methods of treatment to hysterectomy
-- Excessive menstrual bleeding- oral Tablets- hormonal , non hormonal
- hormonal Injection
- LNG-IUCD
-Fibroid- removal fibroid (Myomectomy) / Uterine artery embolization
—Abnormal Pap smear-conservative treatment
-PID-Antibiotic treatment
/TkCAUM Of M
PRESERVE
A
HIDDEN HARMS OF THE HYSTERECTOMY
Luterus.
-The surgery is often accompanied by removal of ovaries to reduce the risk of ovarian cancer.
-There may be vaginal burning, increased urinary frequency and early onset of menopause.
Women who have undergone hysterectomy tend to have increased incidence of heart disease(3 fold) and may also show symptoms of
osteoporosis in an early age.
-Depression
-Metabolic disorders
-Dementia
One of the studies-vvent further and looked at risk by age at hysterectomy. It found that “Women who underwent
hysterectomy at age <35 years had a 4.6-fold increased risk of congestive heart failure and a 2.5-fold increased risk
of coronary artery disease
2
29-01-2024
J. MC*UU0*«
AWARENESS
jfrfa’CTf?'r R'ftifrzrt
Field level
• ANM
• Anganwadi
• Screening program
• Peer group education
• Family health physician
• Awareness about menstrual hygiene among adolescence
• Inform women about consequences of hysterectomy
•
educate women in Local language
AWAKEN ESS-CONTD
12 .
Doctors
-CME
-Uterine preserving surgeries
-Physiotherapy
-Implementation or follow guidelines and manage accordingly
-Training towards less invasive methods than indication for hysterectomy
-Appoint trained counselor
-Attitude
3
29-01-2024
5- BSCWSEOfME
[preserve
AWARENESS
kUTERUSA
Patient
• Educate the patient regarding alternative medication
• Effective counselling-helps her to make a choice
• Regular health check up
• Educate family member
< MCWStOFMi
AWARENESS
Public
Public-private partnerships (PPPs) in addressing complex health challenges in women’s
health like Heavy Menstrual Bleeding and giving an overview of the path breaking work
that has been doing in the realm of women’s health.
Prayas and Sochara also doing the awareness program to bring down the unnecessary
hysterectomy
4
29-01-2024
' Mcwstorw
PRESERVE
UTERUS
CONCLUSION
• Uterus is not a vestigial organ once family is complete
• Removing uterus should be last option and not the first one
• Hysterectomy on demand should not be entertained
• Do evidenced based counselling -don’t create phobia for uterine cancer
• Decision to do hysterectomy is in the domain of gynecologist and not the surgeons
TAKE HOME MESSAGE
The need of the hour is to come forward and support the campaign for better health of our
women and families.
5
29-01-2024
UTERUS J
6
29-01-2024
IMPROVING GYNAECOLOGICAL CARE TO PREVENT
UNNECESSARY HYSTERECTOMIES
ROUND TABLE
Dr. Narendra Gupta
Prayas
Understanding
the Reasons for
RISING NUMBERS OF
HYSTERECTOMIES
National Consultation
12th August 2013
HkLN
1
29-01-2024
’
.
t:
In.li <1 " rnu *
I! • Rm**-
.. ..io»A»toWia
IMfci
<1
*'1' '‘j S
'■,■• .if HvM.'h'domu^ tn htdu
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2
122 Cyclones in Andhra Pradesh
Loss of lives...
Most lives are lost during a cyclone on account of floods and the
Stonn surges
devastating storm surges that often accompany cyclones. In
often kill seven
severe cyclonic storms with storm surges, more than 90 per cent
times more
of the fatalities occur from drowning, either during the incoming
water phase or during the (usually more devastating) out-surges.
people than
severe but storm In severe cyclonic storms without storm surges, the deaths are
more or less evenly divided between drowning and the collapse
surge-free
of
buildings.
cyclones
Storm surges, or mini-tsunamis, are essentially huge amounts of
water sucked up by the low pressure at the eye and then
propelled forwards and outwards by the driving winds on the
outwalls. Storm surge height (up to seven metres) and length (up
to 50 km) depends on the tides, the rate of water runoff from the
land, onshore winds, and the coastal configuration. They cause
the most havoc when they are receding. On an average, storm
surges kill seven times more people and damage three times
more crops than severe but storm surge-free cyclones (Winchester,
Peter, 1992).
For instance in the November 1977 cyclone that hit the KrishnaGuntur-Prakasam-West and East Godavari districts in Andhra
Pradesh, storm surges rose to as much as 9-20 ft, were 80 km
long and 24 km deep, and shot up the death toll to over 8,000,
one of the highest figures ever recorded.
Injury, health impact
One important aspect that requires attention in the aftermath of
cyclones is the injuries and other health impacts on the affected
populace. The most common debilitations are waterborne
diseases such as diarrhoea, dysentery, typhoid, viral hepatitis;
respiratory diseases such as pneumonia and whooping cough,
and other diseases such as chicken pox, measles, gastroenteritis,
cholera, conjunctivitis and fever. Of late, experts have pointed out
that the affected people may suffer from long-term PostTraumatic Stress Disorder (PTSD), characterised by a high
incidence of divorce, alcoholism and suicide.
'LT-
IlJ* ».
'
1 Sharma, VK and Singh, R, Psychosocial Consequences of Disasters: Case Study
of the 1996 AP Cyclone, paper presented at the National Workshop on
Psychosocial Consequences of Disasters, NIMHANS, Bangalore, 1997
29-01-2024
_ POPULATION
Jr COUNCIL
^p
H£PORT
Consultation on
Hysterectomy: New Evidence
& Directions for Research, Advocacy and Programs
M J iA/
Indian Habitat Center. New Delhi
18" September 7018
//
5XiS>±^s...i..ii.. .
MM|MH
3
[Tsunami Evaluation Coalition; Syrrthwls Report: Expanded Summary
4-r—____________ ■,........................................
\
. .
........................... ■
■_
■
.............................................................
_
' .
■
Terminology
This report uses the term 'agencies' to refer to humanitarian actors such as the Red Cross
movement, United Nations (UN) agencies, international non-governmental organisations
(INGOs), and the aid administrations of donor governments. It uses 'affected population' to
refer to the people affected directly by the disaster. These may relate to aid agencies directly
or through their regional and national political structures, depending on the context.
The term 'relief' in the report refers to immediate aid to prevent distress and suffering and
the term 'recovery' to rebuilding people's economic and social lives after the disaster. The
term 'local capacities' refers not only to the resources, skills and knowledge of the local
community, but also to their ability to set and influence policies and to hold accountable those
with a duty toward the community (such as the aid agencies who raised money to help the
affected populations).
'Ownership' in this report refers to the control of the response, to decisions about
programme policies and priorities and the nature of the response.
§
Limitations
The tsunami was a sudden-onset natural disaster and the worst affected countries were
middle-income counties with well-developed local capacities. While some may think this
might limit the general applicability of the TEC recommendations, not only do the operational
problems seen in the tsunami response mirror those seen in complex political emergencies
like Rwanda in 1994 or Kosovo in 1999, but lower income countries can also have significant
local capacities. While every humanitarian crisis needs to be considered in its own context,
the TEC recommendations are therefore considered to be more broadly applicable - and
indeed are probably applicable in the majority of such crises.
The TEC focused on the first 11 months of the response by the international humanitarian
community. It took a sector-wide approach rather than looking at individual agencies. The
TEC reports make some reference to local organisations and national governments, but these
were not the main object of the TEC evaluations. As a result the recommendations from the
TEC are mainly, with a few exceptions, for humanitarian agencies rather than for the people
and governments of the affected countries. The TEC reports do not reflect changes in
practice that may have occurred after the first 11 months. In particular the report does not
deal with the efforts toward humanitarian reform, including the cluster coordination model
and the strengthened Central Emergency Response Fund (CERF).
Summary of TEC findings
The TEC studies found the international response to the tsunami disaster helped the affected
people and reduced their suffering. They identify many examples of good practice in
emergency response, and some welcome innovations. However, overall the studies conclude
that the response did not achieve the potential offered by the generous funding.
*
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29-01-2024
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• .1 GMidr irtH to
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4
7. Comprehensive list of all victims for mass treatment, compensation and
rehabilitation.
Communication
8. Evolve a continuing education strategy for all governmental and non-governmental
health personnel through newsletters and informal group meetings. Identified
areas include:
i)
Sodium thiosulphate therapy; Management of lactation failure
ii)
Identification and management of psycho-social stress
iii) Risks to mothers and unborn foetus and need for surveillance
iv) Family planning advice till completion of detoxification
v)
Role of respiratory physiotherapy, Caution against overdrugging
vi) Need for surveillance of high risk groups, Importance of medical records
9. Dynamic creative nonformal health education of affected community with
information built around their lifestyle, culture and socio-economic status. The
areas identified include:
;•
i)
Sodium thiosulphate therapy; Respiratory physiotherapy
.<)
Ongoing research programmes and informed consent
iii) Risk to unborn and new born babies; Family planning advice
iv) Management of lactation failure including low cost weaning foods
v)
Importance of records and regular checkups
10. Occupational rehabilitation and compensation: to be done imaginatively keeping
in mind their previous occupations and the residual disabilities.
Coordination
11. The government must adopt a policy of enlisting the help of all non-governmental
agencies and groups wishing to work in Bhopal. This process must be active and
supportive.
12. It is imperative that the victims as well as the entire country must be provided
with all the details of how the accident occurred, of the nature of the chemicals
released and of the reasons why the detoxification by sodium thiosulphate has
been so badly mismanaged.
*
SOCHARA - Environmental and Health Report
2S
29-01-2024
■
illg
HUMAN DIGNITY
i
18 December 2023
Rev. Prof. Dr. habil. J. Charles Davis
Associate Director
St. John’s Medical College
St.John’s Research Institute
■
HUMAN DIGNITY
I
1
Pope Paul XIII (b. 1810-Papacy: 1878-1903 CE):
“man precedes the state”
\
Human Dignity in World Religions
Page No: 141
1
immunities. The nature of these health effects suggested a chronic cyanide poisoning
ke mechanism, which added evidence to the existing controversy about how the health:
ffects were caused. Several recommendations were given to the government and other
roups based on this study, and a call was made for the use of evidence-based se/isitive
ction. One recommendation was the controversial support to the use of a compound
jlled 'sodium thiosulphate' to detoxify the victims. Later on, the results of a detailed
:udy by the Indian Council of Medical Research supported the use of thiosulphate
the treatment and rehabilitation of victims. An epidemiological'review paper was
Iso published with the available evidence on mortality and morbidity due to Bhopal
agedy. The evidence generated through these processes was/continuously updated
nd presehted at international conferences including the Per/nanent Peoples Tribunal,
iter that year, mfc also organised a meeting on Pesticides and Health where the health
npacts of the production and use of chemicals in agriculture was discussed.
hiv Vishvanathan, a well known anthropologist wrote/iater about mfc's scientific report
n the health situation in Bhopal as "probably the most sane, compassionate piece
f scholarship on the problem of relief in BhopaT (8). An excerpt from that article is
'ovided in Box.2, which is followed by a deta/ed report on CHC's involvement in the
hopal campaign.
/
Box.2: Excerpt from Imagination of a/disaster', by Shiv Vishwanathan (8)
“But what is most fascinating is th/manner in which text and context are related.
Voluntary health specialists have repeatedly advocated that the focus of study
should be suffering in the community, rather than the patient as an isolate in the
hospital. The first they argu^ leads to a holistic view of disease while the latter
propagates a reductionist view of illness and an atomistic view of the patient. The
latter view which underwrote the pulmonary model, is based on numerous vertical
studies rather than an integrated search for interconnections. In a telling paragraph
the MFC report suggests, 'The approach of examining say 200 eyes or 200 lungs and
so on independent one another lacks this integration. Strange it may sound, but it
seems:to derive the rationale - unconsciously - from the pulmonary model, wherein
toxic gas directl/hits the target organ (lungs, eyes etc) to produce damage without
any intrinsic connections - which is at the heart of the 'cyanogen pool' model'.
It is this anthropology of gestalts that is fascinating about the report. What it offered
were twq/clusters which deserve further exploration:
SOCHARA - Environmental and Health Report
17
29-01-2024
Pope Paul XIII (b.l 881-Papacy: 1958-1963 CE), Pacem in Terris:
the fundamental principle of natural and equal human dignity is the basis
for the universal rights and inviolability of every human being.
Page Nd: 141
Each individual man is truly a person. His is a nature, that is,
endowed with intelligence and free will and intrinsic dignity.
As such he has rights and duties, which together flow as a
direct consequence from his nature. These rights and duties are
universal and inviolable, and therefore altogether inalienable.
\
Page Nd: 141
2
29-01-2024
The debate took place between two members of the
Dominican Order: Juan Gines de Sepulveda (1489-1573)
I
and Bartolome de Las Casas (1484-1566).
1
V
X\
Page. No: 16
Francis de Victoria (1483-1546 CE), another Dominican
Friar and a great theologian shines like a star in the dark
periods of the conquest and colonial Spanish missionary
activities in the Americas.
Page N6: 17
4
29-01-2024
Human Dignity Philosophical Perspectives \
It is difficult to define what human dignity is. It is not an organ
■H
to be discovered in our body, it is not an empirical notion, but
without it we would be unable to answer the simple question:
\ --
what is wrong with slavery? - Leszek Kolakowski.
Page No: 43
Every entity has a value. The value of things may
vary depending on their worth. Dissimilar values
are attributed even to different things of the same
art of kind of species.
Page No: 43
5
29-01-2024
■ Recognition or attribution of values to entities is done
only by humans and never by any animals. In the past,
slavery existed and slaves were bought for a price.
* Slavery is largely abolished today.
■ Humans are considered to have a value or status or
worth which is beyond any price.
Page. Nd: 43
Kant calls the value of humans a priceless “dignity,” meaning
that humans cannot be bought or sold in exchange. However,
not everyone easily accepts an equal (metaphysical) priceless
value of (physical) humans. For example, some consider
intellectuals to have more worth than ignoramuses, righteous
more than criminals.
Page No: 43
6
29-01-2024
► History informs us of the changing use of the term
human dignity from a status of a rank, an inherent value
to a dignified way of living.
► The concept of human dignity, even without a clear
definition, is increasingly used in the international and
national declarations of human rights after World War II.
Page No: 44
The Three Senses of Human Dignity
Daniel P. Sulmasy categorizes the one and the same human
dignity into three senses, namely,
► Intrinsic
y
► Attributed
► Inflorescent dignity.
Page No: 45
7
29-01-2024
THANK YOU
8
GUIDELINES TO PREVENT
UNNECESSARY
HYSTERECTOMIES
MINISTRY OF HEALTH & FAMILY WELFARE
illlS ra
I
' :
1^4:
S
e
1
N
Index
Sr No
Topic
Page No
1
Introduction
2
2
Common Indications for Hysterectomy
4
3
Programmatic Guidelines
• Overview
• Monitoring Mechanisms
• Awareness Generation
7
4
Clinical Protocols for Management by ANMs/ CHOs &
Medical Officers
15
5
Overview of Treatment Modalities
L
6
Annexures
1) Roles of Different Providers
2) Basic Facts about Hysterectomies
3) Guidance on Audits for Hysterectomies
4) Detailed Treament Modalities for AUB/ DUB
22
I
INTRODUCTION
Hysterectomy, the surgical removal of the uterus, is the most common nonobstetric gynaecological surgery amongst women in reproductive age group. The
most common medical indications for hysterectomy include fibroids, abnormal
uterine bleeding, uterine prolapse, chronic pelvic pain and premalignant and
malignant tumours of uterus and cervix. Hysterectomy with Oophorectomy
(Removal of ovaries) leads to surgical menopause which may further lead to
menopausal symptoms such as hot flashes, vaginal dryness, urinary incontinence,
sexual dysfunction and long term consequences like osteoporosis and CVS diseases.
Oophorectomy worsens the symptoms of early menopause.
In developed countries, hysterectomy is typically conducted amongst pre
menopausal women above age 45 years. In India, there is increasing concern about
patterns of hysterectomy at a population level. Community-based studies have
consistently found rising hysterectomy rates amongst young women, rangingfrom
28 to 36 years. Further, evidence indicates a higher risk amongst poor, less
educated women in rural areas. Field-based reports have also suggested that there
are unnecessary hysterectomies performed in cases where medical or non- invasive
treatment would have been sufficient. There are also reports of potential coercion
for financial benefit under health insurance schemes and concerns pertaining to
lack of information provided to women on side effects.
Data from the National Family Health Survey-4 (2015-16) estimates hysterectomy
prevalence to be 3.6% amongst women 30-39 years and 9.2% amongst women 4049 years. The median age at hysterectomy was 37 years (amongst womenwho
were 40-49 at the time of survey). Two-thirds of procedures were conductedin
private facilities. Excessive menstrual bleeding or pain was self-reported as the
leading indication for hysterectomy, followed by fibroids and uterine disorder.
Prevalence varied greatly across states, with prevalence from 20-23 percent of
women in ages 40-49 in Andhra Pradesh and Telangana—close to high-income
countries—yet at a considerably low median age. Data also show variation across
states indicating uneven availability of treatment for women for common
gynaecological disorders at primary health care level1. NFHS 5
A working paper from the National Health Authority on early trends from
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY) indicates that
2% of claims submitted for women were for hysterectomy. Six states (Chhattisgarh,
Uttar Pradesh, Jharkhand, Gujarat, Maharashtra and Karnataka)
1 Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: a national and state-level
analysis of the Fourth National Family Health Survey (2015-2016) [published correction appears in
BJOG. 2020 Oct;127(11):e122. Shuka, A [corrected to Shukla, A]]. BJOG. 2019; 126 Suppl 4(Suppl
Suppl 4):72-80. doi:10.1111/1471-0528.15858
2
had overall high number of claims under PM-JAY and also generated three- quarters
of all hysterectomy claims. The median age of claims submitted for hysterectomy
under PM-JAY was 44 years. The most common package covered was hysterectomy
with salpingo-oopherectomy, suggesting that up to half of claimants may have
undergone removal of the ovaries, which in turn may render women vulnerable to
a range of side effects.
A national consultation in 2019 on unnecessary hysterectomy identified three
important challenges for women's health:
* The need for appropriate clinical and population-level guidelines on
hysterectomy
* Availability of appropriate information on and treatment of gynecological
morbidity at the primary care level
* A critical need to monitor and regulate the appropriate use of hysterectomy,
particularly for treatment of benign gynecological conditions and amongst
younger women.
The purpose of this document is to:
1. Provide guidance to public health programme managers on measures to
address unnecessary hysterectomy at the facility level, including focus on
monitoring and awareness generation activities at the community level.
2. Provide clinical guidelines on common conditions that constitute key
indications for hysterectomy. To focus on providing treatment pathways for
abnormal uterine bleeding/dysfunctional uterine bleeding, lower
abdominal pain, vaginal discharge, abnormal looking cervix and
uterovaginal prolapse, drawing from existing government guidelines,
evidence reviews and expert consultation.
3
COMMON INDICATIONS FOR HYSTERECTOMY
Evidence reviews and expert consultations have highlighted the following
common indications for Hysterectomy in our country:
• Abnormal Uterine Bleeding/ Dysfunctional Uterine Bleeding
• Vaginal Discharge
• Lower abdominal pain/Pelvic Inflammatory Disease (PID)
• Abnormal looking cervix
• Uterocervicovaginal Prolapse
ABNORMAL UTERINE BLEEDING
Abnormal uterine bleeding (AUB) is a broad term that describes irregularities in the
menstrual cycle involving frequency, regularity, duration, and volume of flow outside
of pregnancy. Up to one-third of women will experience abnormal uterine bleeding in
their life, with irregularities most commonly occurring at menarche and perimenopause.
A normal menstrual cycle has a frequency of 24 to 38 days, lasts 7 to 9 days, with 5 to 80
ml of blood loss. Variations in any of these 4 parameters constitute abnormal uterine
bleeding. Older terms such as oligomenorrhea, menorrhagia, and dysfunctional uterine
bleeding should be discarded in favour of using simple terms to describe the nature of
the abnormal uterine bleeding. Revisions to the terminology were first published in
2007, followed by updates from the International Federation of Obstetrics and
Gynaecology [FIGO] in 2011 and 2018. The FIGO systems first define the abnormal
uterine bleeding, then give an acronym for common aetiologies. These descriptions apply
to chronic, nongestational AUB. In 2018, the committee added intermenstrual bleeding
and defined irregular bleeding as outside the 75th percentile.
Abnormal uterine bleeding can also be divided into acute versus chronic. Acute AUB is
excessive bleeding which requires immediate intervention to prevent further bloodloss.
Acute AUB can occur on its own or superimposed on chronic AUB, which refers to
irregularities in menstrual bleeding for most of the previous 6 months.
table Potential causes of abnormal uterine bleeding
according to the PALM-COEIN classification5
Polyp
Aden omyosls
Structural pathology measurable
through Imaging or histopathology
Leiomyoma
Malignancy & hyperplasia
Coagulopathy
Ovulatory disorders
Bleeding unrelated to structural
abnormalities
Endometrial dysfunction
Iatrogenic
Not otherwise classified
4
UTEROCEVICAL AND UTEROVAGINAL PROLAPSE
Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and
no longer provide enough support for the uterus. As a result, the uterus slips down into
or protrudes out of the vagina. Uterine prolapse can occur in women of any age. Butit
often affects postmenopausal women who have had one or more vaginal deliveries. Mild
uterine prolapse usually doesn't require treatment. But if uterine prolapse starts
interfering with the routine activities and disrupts the normal life then benefit occurs
from the treatment. The management of uterovaginal prolapse is age and fertility related.
Not everyone requires hysterectomy. The conservative surgical operations are gaining
more popularity. Several sling operations are available now.
VAGINAL DISCHARGE
Vaginal discharge is one of the most common presenting symptoms of women to a
doctor's office. It may be pathological or physiological. It may affect women of any age
group. Even when it is pathological, it may be treated by means of antibiotics prescribed
to the woman and often times also to her partner. However persistent vaginal discharge
despite treatment requires further investigation. Vaginal discharge which is not treated
or inappropriately treated can start interfering with the routine activities, affect the
woman's ability to work and also give rise to more severe forms of pelvic infections, often
leading women to opt for hysterectomy specially in the underdeveloped sectors ofthe
country where referral centers are not easy to approach. It is very important both for the
patient and the health care provider to understand that hysterectomy is not a treatment
of vaginal discharge.
LOWER ABDOMINAL PAIN:
Lower abdominal pain or pelvic pain are common complaints compelling women to
visit the health care provider. This pain may be acute or chronic. Most commonly it is
the chronic pelvic pain, the causes of which may be difficult to diagnose, hence making
treatment difficult. Owing to this often both the health care provider and the patient
resort to hysterectomy as the final answer. The most common cause of chronic pelvic pain
in women is Pelvic Inflammatory Disease (PID). Treatment of PID is mostly outpatient
and non-surgical requiring a prolonged course of antibiotics. Only a few patients
presenting with acute symptoms like high grade fever and increased blood counts may
require admission. Conservative surgery may be needed only in cases with pelvic abscess.
5
Pre-cancerous Lesions of Cervix / Unhealthy Cervix:
Chronic cervicitis or pre-cancerous cervical lesions may often lead to an unhealthy looking
cervix with chronic discharge, which may be treated by medical management or cervical
ablation or excisional techniques. Hence, an unhealthy looking cervix requires evaluation to
rule out cancerous or precancerous lesions but does not require hysterectomy in all cases.
6
PROGRAMMATIC
GUIDANCE
"7
PROGRAMMATIC GUIDANCE
The purpose of this section is to provide programme managers guidance on
prevention of unnecessary hysterectomy by raising awareness among health providers
regarding alternative methods of treatment available for gynaecological diseases as well
as in the community regarding indications of hysterectomy and disadvantages of
unnecessary hysterectomy. While the burden of hysterectomies varies across states,
variation in national patterns suggests a lack of uniform services available to treat
gynaecological morbidity. Hitherto the health system has focused largely on obstetric and
family planning services, aligned with the aim to reduce maternal mortality and address
unmet need for family planning. Accordingly, financial and human resources at all levels,
including outreach services, were primarily related to pregnancy, delivery, post -partum
care and family planning. As of now, other than Community Health Centres, District
Hospitals and Medical Colleges, there are limited services in public health facilities to
treat or appropriately refer women with gynaecological complaints. Women often
undergo surgery for gynaecological conditions may possibly respond to medical or nonsurgical interventions. The lack of services for such conditions have r~
---- --reasons
many
including high obstetric case-loads, a shortage of Medical officers and specialists,, and on
account of limited knowledge among service providers on updated methods of non
surgical methods for treatment.
Programme officers are expected to ensure training of all cadres of workers
including the ones at the frontline, supply of medicines and other logistics, enable the
delivery of high quality services at primary and secondary care levels including provision
of NCDs at HWC's and create the mechanism for community awareness and facilitate the
conduct of medical and social audits.
The role of programme managers in reducing unnecessary hysterectomy is to:
1. Communicate the range of interventions to be provided at each level of the
health system for gynecological as well as obstetric ailments and thereby
eliminate unnecessary hysterectomy
2. Build capacity of secondary and primary level service providers (Medical
Officers, Staff Nurses, CHOs, LHV/ANMon women’s health needs for
gynecological services
3. Ensure that the PHC team at Health and Wellness Centers is able to make
appropriate referrals and ensure that medicines prescribed at the higher
levels is dispensed at HWC-SHC (If available} and that continuum of care is
maintained
4. Enable improved public understanding of the various gynecological
problems a woman may develop, the plethora of medical management and
non- surgical interventions available to treat them, the consequences of
unnecessary hysterectomy and guide women on care-seeking for
gynecological morbidity through building community awareness
8
5. Ensure awareness regarding publicly financed health insurance like PMJAY
amongst those who are eligible for the scheme and are required to undergo
indicated hysterectomy in order to reduce out of pocket expenditure and
thus provide financial protection.
9
Role of Different Levels of Public Health Facilities
The role of HWCs/SC/PHC/CHC/SDH/DH/MC according to conditions leading
to/associated with Hysterectomy, have been listed for the common conditions:
la. Abnormal Uterine Bleeding (Menorrhagia with normal sized uterus] with/without
dysmenorrhoea
lb. Abnormal Uterine Bleeding (Menorrhagia with enlarged uterus]
lc.Abnormal Uterine Bleeding: Metrorrhagia, Oligomenorrhoea, Amenorrhoea
followed by irregular bleeding in high risk group (obese, hypertensive, diabetic or a
family history of endometrial or cervical cancer], AUB in women above 40 years of age
OR Persistent dysmenorrhoea
2. Abnormal Vaginal Discharge ± Pelvic pain ± Backache
3. Utero-cervical prolapse
4. Lower abdominal pain
5. Abnormal or unhealthy cervix
6. Post - hysterectomy care in women who have undergone hysterectomy at age less
than 45 years.
7. Emergency hysterectomy performed to treat uncontrolled PPH
Annexure 1 provides details on what is expected at each level of the health
system (HWCs/SC/PHC/CHC/SDH/DH/MC] for common gynaecological symptoms, the
role of the service provider at each level, and details of services including essential drugs
and diagnostics to be provided at the level of the facility.
Community Awareness
It is essential that facts about hysterectomy are available to the community.
Existing platforms such as Village Health, Sanitation and Nutrition Committees, Women's
Self-Help Groups, Mahila Arogya Samities, and Rogi Kalyan Samities at PHC, CHC and
district hospitals could be used to disseminate information through frontline workers
such as ASHA and MPW- F. Discussions should focus on removing myths and
misconceptions in the community and raising awareness on menstrual hygiene practices,
prevention of PID's and STD, safe sex practices, other gynaecological problems in women,
risk factors for genital tract malignancies and plenty of treatment modalities available for
treatment as well as the role of hysterectomy in these conditions. Emphasis should be
laid on the fact that hysterectomy is not the first choice of treatment for most conditions.
This section of the document provides guidance on developing programs to build
community awareness on unnecessary hysterectomy. It focuses on providing basic facts
on hysterectomy and components of a communication strategy.
10
Basic Facts on Hysterectomy
It is essential that facts about hysterectomy are available to the community and
community health workers in particular. Annexure 2 provides clear, simple information
on hysterectomy that can be used to raise community awareness.
Communication strategies
Existing agencies that can help build awareness in the community:
1. Village Health, Sanitation and Nutrition Committee in each village
2. Women's Self Help Groups linked to each Anganwadi
3. Mahila Aarogya Samitis
4. Mother's group in each Anganwadi
5. Standing Committee on Health in every gram panchayat
6. School Management Committees in every school
7. Rogi Kalyan Samities at PHC, CHC and district hospitals
8. Other community based organizations
9. Ward and gram sabhas
10. District Health Societies
Principles for community awareness on hysterectomy prevention:
1. Community awareness building should be done in local language and IEC materials
must be developed accordingly
2. All FAQs must be translated into local language. Print material, videos and apps can
be used. Apps must be free to use once downloaded and usable offline. They can
provide information on menstrual hygiene and hysterectomy related information
for both service providers and women
3. LNG IUS must be promoted as a low cost non-surgical alternative to
hysterectomy where ever feasible
4. Testimonies of women who experienced adverse effects after hysterectomy
Testimonies of caregivers who witnessed adverse effects following hysterectomy
5. Professional Testimonies of doctors, Counsellors, Journalists, Teachers etc
—
Yc u can make a difference by:
nuuity
• Re moving mvths and misconceptions in the
• At oiding unnecessary Hysterectomies
•
Ca mpaignmg for preventing unnecessary Hystere
_______________________
The training for all levels may be conducted through existing NCD platform.
11
Key components
hysterectomy
of a__communication strategy to address
unnecessary
Designing a Communication Strategy2
1. Key
Messages
Literature Review;
Formative Research
2. Target
Population
a.
Findings from formative research can
be used to develop and design
customized and standardized messages
for behaviour change.
Policy Makers - sensitization and advocacy with policy makers for
creating policies and institutional mechanisms to prevent
unnecessary hysterectomy (bureaucrats, executives etc.]
b. Service providers - sensitization and advocacy with service
provides (such as doctors, RMPs, Nursing Homes etc.] for uptake of
desired practices of change
c. Community Women: the women and her immediate family members are
made aware of, and are encouraged to follow desired practices
ofchange
• Influencers: (relatives, peer, fellow villagers, doctors, RMPs,
nursing homes, labour contractors, employers etc.] are made
aware of, and are encouraged to promote the dissemination and
uptake of desired practices of change.
3. Platforms
Workshops, Seminars (for policy makers, executives, service
providers etc.]
• Community level Events and Institutions (such as VHSNDs, AWCs,
SHGs, Gram Sabha, Health Centres, Schools/ School Management
Committees/ PTAs etc.]
• Labour Chowks, Brick Kilns, Sugar Factory/ Farms, Railways
Stations, Bus Stations etc.
4. Medium
a. Docudrama (Video-based
Approach]
•
b. IVR (Community Radio]
Use community based video
production or employ professionals
to produce small docudramas.
• Videos produced can be screened at
the various platforms (above] or
sent through WhatsApp, or
broadcasted on local TV
• PICO projectors, smart phones, and
TAB can be used for screening
videos
•
Use a combination of push and pull
call system
7 Indicative only
12
c. Wall Painting/ Flip
charts/ Dangles, Flyers
etc. (Conventional
Approach)
d. TV, Radio, Social Media,
WhatsApp
5. Change
Agents
•
•
•
•
Allow the user to call on a Toll Free
Number and listen to pre-recorded
FAQs or record her queries.
•
Wall paintings at railways stations,
labour chowk, PHC, etc.
Specific posters for each level of
Facilities.
•
•
Whats App can become an effective
medium of dissemination
Frontline workers of various government departments (ASHA, ANM,
AWW etc.)
Community institutions (Women’s groups, Farmers groups, Gram
Panchayat, School Management Committees etc.)
Doctors, RMPs, Labour Contractors, Labour Employers
** Influencers like RMPs, labour contractors and employer can be
highly effective if sensitized and encouraged to undertake the role of
change agent.
6. Monitoring
and
Evaluation
•
Identify suitable indicators of monitoring and evaluation of the
communication interventions like : No. of Hysterectomy cases
conducted < 40 years and cause of hysterectomy.Design a system of
continuous tracking of practices and trends around women's health
and unnecessary hysterectomy.
13
Monitoring & Evaluation
Reporting of hysterectomy like; No. of Hysterectomy cases conducted < 40 years
and cause of hysterectomy need to be incorporated in the existing NCD screening
checklist. Data pertaining to Hysterectomies must be regularly monitored at both State
and District levels. Data from both public and private sector needs to be monitored and
government institutions, medical professionals from both public and private sector as
well as other stakeholders must come together to make this monitoring a success.
District Hysterectomy Monitoring Committees
A District Hysterectomy Monitoring Committee must be set up in each district
to enable effective monitoring. The committee must be set up under the chairpersonship
of District CMO. NCD Nodal, District RCH Nodal Officers / Maternal Health Nodal Officers,
other key government personnel at the district level, representatives from FOGSI (both
public and private sector), representatives from development partners etc. The
monitoring committee is expected to:
•
•
Issue necessary orders to both public and private sectors to submit a line list of all
women who underwent hysterectomy every month. The line list must include
information on parameters such as:
o Age
o Parity
o Occupation
o Indication of hysterectomy
o Previous medical/surgical history
o Hysterectomy route:
■ Abdominal
■ Vaginal
■ Laparoscopic
o Any other surgery done along with hysterectomy:
o Past treatment history:
o HPE:
Every quarter the district committee must audit cases with following indications
and issue necessary instructions if required:
o Hysterectomy with/ without BSO in women <35 yrs. of age
o Hysterectomy with BSO in women < 40 yrs. of age
o All cases where no indication for doing the procedure is mentioned in the
records
o All cases where no records of treatment prior to hysterectomy (in papers
or in history) are available
o Discrepancy between mentioned indication and HPE report
o Any severe morbidity/mortality due to hysterectomy
14
•
Annexure 3 provides detailed guidance on how to conduct audits of
hysterectomies
Arrange necessary trainings and sensitization sessions for both public and
private sector professionals.
State Hysterectomy Monitoring Committees
A State Hysterectomy Monitoring Committee must be set up in each State to
enable effective monitoring. The committee must be set up under the chairpersonship of
State Principle Secretary. State level DPH (Director Public Health) will be the nodal
Officer & NCD State program officer, RCH/FW/MH programme officers will be the other
key government personnel at the state level, representatives from FOGSI (both public and
private sector), representatives from development partners etc. The monitoring
committee is expected to meet once in every six months and review district level data to
ensure that unnecessary hysterectomies can be avoided. The State Hysterectomy
Monitoring Committees must also arrange necessary trainings and sensitization sessions
for both public and private sector professionals and district officials.
National Hysterectomy Monitoring Committees
A National Hysterectomy Monitoring Committee must be set up to enable
effective monitoring and ensure necessary policy decisions at the National level. The
monitoring committee would comprise of officials from NCD, ICMR, MH Officers under
the chairpersonship of Additional Commisssioner & Mission Director, NHM and is
expected to meet once in every six months and review State level data to ensure that
unnecessary hysterectomies can be avoided. The national committees must also arrange
necessary trainings and sensitization sessions for both public and private sector
professionals and district officials. Most importantly national committees must review
the landscape and take necessary policy decisions as required.
15
CLINICAL
PROTOCOLS
16
This section focuses on clinical protocols for management at the level of ANMs and at
the level of CHOs/ Medical Officers.
17
VARIOUS
MANAGEMENT
HYSTERECTOMY
MODALITIES
AVAILABLE
FOR
This section deals with various treatment modalities available for common
indications of hysterectomy namely Abnormal Uterine Bleeding/ Dysfunctional Uterine
Bleeding, Uterocervicovaginal Prolapse, Vaginal Discharge, Pelvic Inflammatory Disease
(PID) & Abnormal Cervix
MODALITIES OF MANAGEMENT AVAILABLE FOR AUB/ DUB
Choice of treatment for AUB/DUB depends on clinical stability, suspected aetiology of
bleeding, desire for future fertility and underlying medical problems. The two main
objectives of managing acute AUB are:
1. ] To control the current episodes of heavy bleeding
2. ) To reduce menstrual blood loss in subsequent cycles
Medical therapy is considered the preferred initial treatment.
Medical management:
Medical treatment options for DUB include tranexamic acid, nonsteroidal anti
inflammatory drugs [NSAIDs}, combined oral contraception pill, progestogen, danazol
and gonadotropin-releasing hormone analogues (GnRH-aJ. Another medical method for
the treatment of DUB is the levonorgestrel-releasing intrauterine system (Mirena®). It
was originally developed as a contraceptive method , but it has been proven quite
effective in the treatment of DUB, so the device acquired approval for that indication
too.
Surgical methods: In cases of AUB resistant to medical treatment, physicians should offer
to women surgical treatment. In such patients, one could choose between endometrial
ablation techniques and hysterectomy, taking into consideration patient's age, physical
condition, and will.
Detailed treatment modalities for AUB/ DUB are annexed (Annexure 4).
18
MODALITIES OF MANAGEMENT AVAILABLE FOR UTERO VAGINAL PROLAPSE
Uterovaginal prolapse is also not a direct indication of hysterectomy specially in younger
age group. In elderly age group hysterectomy is the better option. There are new
modalities of conservative surgeries in the form of various sling operations which have
been recommended in order to avoid hysterectomy.
Various sling operations are -
•
•
•
•
•
•
•
Shirodkar sling
Purandare cervicopexy
Khanna sling
Soonawalla sling
Joshi sling
Virkud sling
Others
There are also different types of reconstructive surgeries:
Fixation or suspension using your own tissues (uterosacral ligament suspension and
sacrospinous fixation]—Also called "native tissue repair/' this is used to treat uterine
or vaginal vault prolapse. It is performed through the vagina. The prolapsed part is
attached with stitches to a ligament or to a muscle in the pelvis. A procedure to prevent
urinary incontinence may be done at the same time.
• Colporrhaphy—Used to treat prolapse of the anterior [front] wall of the vagina and
prolapse of the posterior [back] wall of the vagina. This type of surgery is performed
through the vagina. Stitches are used to strengthen the vagina so that it once again
supports the bladder or the rectum.
• Sacrocolpopexy—Used to treat vaginal vault prolapse and enterocele. It can be done
with an abdominal incision or with laparoscopy. Surgical mesh is attached to the fr ont
and back walls of the vagina and then to the sacrum (tail bone]. This lifts the vagina
back into place.
• Sacrohysteropexy—Used to treat uterine prolapse when a woman does not want
a hysterectomy. Surgical mesh is attached to the cervix and then to the sacrum, lifting
the uterus back into place.
• Surgery using vaginally placed mesh—Used to treat all types of prolapse. Can be used
in women whose own tissues are not strong enough for native tissue repair. Vaginally
placed mesh has a significant risk of severe complications, including mesh erosion,
pain, infection, and bladder or bowel injury. This type of surgery should be reserved
for women in whom the benefits may justify the risks.
•
19
MODALITIES OF MANAGEMENT AVAILABLE FOR PRE-CANCEROUS LESIONS OF
CERVIX / UNHEALTHY CERVIX:
Cervical screening is recommended in:
•
All symptomatic women giving history of chronic leucorrhoea, postcoital
bleeding or unhealthy appearance of cervix should be investigated with VIA or
Pap smear.
•
Age 30-65 years
•
•
All HIV infected women as soon as the infection is diagnosed
Women having symptoms and visible growth, plaque that bleeds on touch:
Cervical biopsy from the growth/lesion
Women having infective discharge: Antibiotics. Follow up after 7 days.
•
Medical Treatment for cervical infection
Cefixime, 400 mg orally single dose plus Azithromycin, 1g orally single dose 1 hour
before food
• Treatment of partner
• Getting HIV,VDRL test
• Follow-up after 7 days
• When there is no infection conduct the following tests
•
Evaluation
1) Visual Inspection (Visual Inspection after acetic acid (VIA), or LugoTs iodine
(VILI)
•
Visual inspection of cervix after painting it with 4-5% acetic acid for 1 minute or
and turn yellow after application of iodine. If VIA is negative assure the woman.
Repeat VIA every 5 years
•
If VIA test is positive (shows dense white, opaque acetowhite lesions in
transformation zone) - colposcopy and directed biopsy should be done.
2) Pap smear / Liquid-Based Cytology (LBC) (if available)
•
Send the smears to pathologist requesting for results as per Bethesda system
(2001). Review the result of smear.
•
With ASCUS cytology do colposcopy or VIA, followed by biopsy if suspicious areas
are identified. Alternatively, it can be triaged with repeat cytology at one year.
Women with cytology report LSIL should preferably undergo colposcopy and
directed biopsy.
•
•
Women with cervical cytology report of ASC H or HSIL should be advised to
undergo colposcopy and directed biopsy.
Women with cytology report of atypical glandular cells should be evaluated with
colposcopy and directed biopsy along with endocervical and endometrial sampling.
20
3) HPV testing: for high-risk HPV type if available and affordable. Negative HPV test
with other tests is more assuring and can help prolong the repeat screen interval to 5
years.
Treatment of CIN on Histopathology of biopsy specimen
• Women having low-grade (ASCUS / LSIL) Pap smear and CIN 1 on histology
should be advised to continue with 1 yearly follow up with VIA/Pap smear under
supervision.
• Women with high grade (ASC-H, HSIL) smear abnormalities and CIN 1 histology
should be advised cytology after 6 months or immediate treatment depending on
their compliance and desire.
• If high grade smear abnormality persists for 12 months and no lesion is seen on
colposcopy a diagnostic excision should be performed.
• With CIN 2/3, if colposcopy is adequate, both excision and ablation are adequate
modalities of treatment. Excision is preferred to ablation.
• Excision is recommended if recurrent CIN, endocervical involvement or
colposcopy is inadequate.
• Immediate hysterectomy for CIN2/3 is unacceptable.
• Hysterectomy can be an alternative to repeat excision/ cone biopsy is feasible.
• If biopsy shows invasive cancer at any time, staging and management according
to the stage of disease should be done in the appropriate center.
MODALITIES OF TREATMENT AVAILABLE FOR VAGINAL DISCHARGE
Vulvo vaginal infections are among the most frequent disorders for which patients seek
care from gynecologists. By understanding the pathophysiology of these diseases, and
having an effective approach to their diagnosis, physicians can institute appropriate
antimicrobial therapy to treat these conditions and reduce long-term sequelae.
Common Causes:
• Vaginitis can be of three types: Trichomona!, candidial vaginitis. Bacterial
vaginosis. Mixed.
• Cervical infection due to gonorrhea and Chlamydia infection.
•
Genital herpes.
Normal vaginal discharge:
Normal vaginal secretions are floccular in consistency, white in color, and
usually located in the dependent portion of the vagina (posterior fornix).
Treatment:
• Depends on accurate diagnosis based on symptoms and examination findings
• Once diagnosed can be managed with antimicrobials
• If clinical examination is suggestive of enlarged uterus, adnexal mass or tenderness
in pelvis then patient should be referred for ultrasonography.
21
Exclude HIV infection, diabetes mellitus, immunosuppressive conditions, steroid
therapy in cases of recurrent infection and refer to higher center.
MODALITIES OF TREATMENT AVAILABLE FOR LOWER ABDOMINAL PAIN (D/T
Reproductive age group women often present with chronic lower abdominal pain
treSa°ted h
7
Vaginal diSCharge and painful ^struation which can be
p , d
medlcaI treatment. One of the common causes of lower abdominal pain is
Pelvm inflammatory disease (PID}. It is caused by microorganisms colonizing the
docervix and ascending to the endometrium and fallopian tubes. Other causes ofpain
may be endometriosis, adenomyosis, pelvic adhesions, adnexal mass or fibroid uterus.
Diagnosis
•
•
Should be based on history and examination.
Traditionally, the diagnosis of PID is based on a triad
of symptoms
and signs,
signs
triad of
symptoms and
offevtr"8 Pe VIC Pain' CerV‘Cal mOti°n and adneXal tenderness- and the Presence
•
Ultrasonography may be advised in cases with palpable masses in the pelvis or in
cases with acute tenderness.
Treatment of Lower Abdominal Pain:
• Treatment is directed to the cause.
• Treatment of infection.
• Medical treatment for endometriosis, (OCP/ progestogens-MPA/Dienogest ,GnRHaj
• Laparoscopic adhesiolysis, fulguration of endometriotic lesions, etc.
• Sometimes the woman may not have any gynecological cause for pelvic pain.
a0bdom?n^ TR
SUCh aS gastrointestinal infections or infestations or
abdommal TB could be responsible which can be treated with appropriate
antimicrobial agents.
H
Correct Anemia, under nutrition & Improve general health
22
Annexure 1
Table: Responsiveness at various levels of care
’
i
la. AUB - Menorrhagia with normal sized uterus, with or without dysmenorrhoqa
nes
'
Point^fCare
^st
of
j
Diagnostics
Provider
(Ess
IListof
il L!
Diagnostic
..
_________________L_-__P
__
J ASHA/MASr
•
Annual screening of women using checklist for Abnoi mal Uterine
Bleeding (AUB).
•
Oral iron and calcium with Ds supplementation. (Daily
requirement of Oral Iron-60mg elemental iron and daily requirement of
Calcium-500mg.
ASHA/ANM:
•
Ensure follow up of women taking treatment for Abnormal
Uterine Bleeding during home visits.
CHO
Hb (initial and
If women fit into
I°n
when
needed
category
la
after
Refer all women with
HC
during
follow
assessment at PHC
Heavy Menstrual Bleeding to
up)
and are advised
PHC for initial assessment.
Dispensing and follow medical
management by PHC
up in subsequent cycles.
MO (MBBS), then
dispense following
Medical Officer(MO)
drugs in subsequent
Initial assessment (history
cycles:
taking, examination including
• Tab. Tranexamic
per speculum and bimanual
Acid 500 mg
examination by SN) at first
•
Combined Oral
. visit of all women with AUB .
Contraceptive
Refer women to
•
Iron (Oral) 60 mg
Gynaecologist if
elemental iron
(a) menorrhagia + enlarged
/day.
firm/ irregular uterus or
• Tab. Diclofenac
(b) metrorrhagia or
(c) intermenstrual bleeding or
100 mg
• Tab. Mefenamic
(d) menorrhagia + normal
uterine size if woman > 40 yrs.
acid 500 mg
(e) acute menorrhagia or (0
• Oral
MPA(Medroxy
severe anaemia
(g) tenderness on uterine
Progesterone
Acetate)
motion
(h) restricted uterine mobility • Tab. Nor(i) adnexal mass or fullness
Ethisterone
Z
Tele-consultation with
acetate 5 mg
Gynaecologist for
. Inj DMPA
management of women< 40
150mg/mI
yrs. with menorrhagia and
. LNG IUD
_J
normal uterine size without
23
vice^ 7 ; ledicines^-;.^;Jr
irnan Resource/ Service
; |
severe anaemia.
Refer to Gynaecologist for
relapse or persistent
complaints after three months
of medical treatment.
''Itvi
(Levonorgestrel
intrauterine
device).
(byMBBSMOonly)
..
fl*-I
K' Gynaecologist
i
□
' ■?
■
Tab. Tranexamic
Acid 500 mg
• Combined Oral
Contraceptive
• Iron (Oral) 60 mg
elemental iron
/day
•
Parenteral
Iron (20mg/ml, total
dose of lOOmg/day)
•
•
■
11
■
■
/
i
Tab. Diclofenac
100 mg
• Tab. Mefenamic
acid 500 mg
• Oral
MPA(Madrox
Progesterone
Acetate)
• Tab. NorEthisterone
acetate 5 mg
• Inj DMPA
150mg/ml
• LNG IUD
• SERM:
Tamoxifen-20mg
/Day
Raloxifene60mg/Day
Bazedoxifene20mg/Day
Ospemifene-
USG
Hb
Coagula
tion profile
S
Sickling
Thyroid
profile
S. Ferritin
If
Gynaecologist
is available at
CHC:
Endome
trial
aspiration/sam
pling if needed
D&Cif
needed
Endome
trial Ablation
(Nonhysteroscopic)
Hystere
ctomy if
needed
24
/'Service
<
Le
I
Med[mines
ir';”oc
(Esse„tIalLlstof
r
edicines)
60mg/Day
•
I
•
■
u
Point of Care
Diagnostics
Inj.GnRH
analogues
(Gonadotropin
Releasing
Hormone) eg. Inj.
Leuprolide
3.75mg monthly.
lb. Abnormal Uterine Bleeding (Menorrhagia with enlarged uterus)______________
Community ASHA/MAS:
Annual screening of women using checklist for AUB
/SubHealth .
Oral iron and calcium with D3 supplementation. (Daily
Centre
requirement of Oral iron-60mg elemental iron and daily requirement of
Calcium-SOOmg.
■
HWC/
Primar
Health
Centre/
.
PS
?
■
ASHA/ANM:
•
Ensure follow up of women taking treatment for AUB during
home visits.
S Tab. Tranexamic Acid 500 mg
CHO
S Refer to centre where Gynaecologist and USG are
MO
available.
S Provide care (including dispensing drugs if MBBS
MO) during subsequent months to women whose
medical treatment has been started by
gynaecologist or who have undergone surgical
management for AUB.
Oral/ Parenteral Iron therapy if needed.
______
25
_ ____
c—
ity
Heah
Centre/jJ
s*JbM1YiSI?n
Hospital
/District
I Hospital/
Tertiarv
Care/ .
_
_
,
■
College
Gynaecologis
t
Tab. Tranexamic Acid
500 mg
• Combined Oral
Contraceptive
• Iron (Oral) 60 mg
elemental iron /day
•
Parenteral Iron
(20mg/ml, total dose of
lOOmg/day)
•
Tab. Diclofenac 100 mg
Tab. Mefenamic acid
500 mg
Oral MPA(Medroxy
Progesterone Acetate)
Tab. Nor-Ethisterone
USG
acetate 5 mg
Hb
• Inj DMPA 150mg/ml
Coag profile
• LNGIUD
Sickling
• SERM:
Thyroid Profile
Tamoxifen-20mg /Day
S
S. Ferritin
Raloxifene-60mg/Day
Endometrial
Bazedoxifene-20mg/Day
aspiration/Sampling if
Ospemifene-60mg/Day
needed
S
PCV transfusion
if needed
• Inj.GnRH analogues
D&C if needed
(Gonadotropin
S
Hysteroscopy /
Releasing Hormone)
guided biopsy
Hysterectomy if
• Tab Ulipristal (As
needed
Contraceptive30mg/Day and non
contraceptive5mg/Day)
•
MM
8
w
u
Jit ■ Ml
J
?6
1c AUB -Metrorrhagia, Oligomenorrhoea, Amenorrhoea- irregular bleeding in high
risk group (obese, hypertensive,diabetic, family history of endometrial /cervical
cancers), AUB in women > 40 years of age, OR Persistent dysmenorrhea
Community
I Sub Health
Centre
ASHA/MAS:
•
Annual screening of women using checklist for AUB
•
Oral iron and calcium with Ds supplementation. (Daily
requirement of Oral iron -60mg elemental iron and daily requirement
of Calcium- 500mg.
ASHA/ANM:
•
Ensure followup of women taking treatment for AUB during
home visits.
S
UPT
CHO
S
Refer to centre where Gynaecologist and USG is
MO
available.
HWG/
Pnmaiy
Health
Centr
Gynaecologis
t
Gen re,
Sub
;ion
Hos
/Dis
Hos
1
Medical
Co
'■
■
• USG
• Hb
• Sickling
• Thyroid Profile
• S. Ferritin
• Coag profile
• Endometrial
aspiration/Sampling
if needed
• PCV transfusion if
• Tab. Diclofenac 100 mg
needed
• Tab. Mefenamic acid
• D&C if needed
500 mg
• Hysteroscopy /
• Oral MPA(Medroxy
guided biopsy
Progesterone Acetate]
• Conservative
• Tab. Nor-Ethisterone
surgical
acetate 5 mg
management for Pre• Inj DMPA 150mg/ml
malignant lesions
Hysterectomy if needed
• LNG IUD
(including surgical
• SERM:
management of
Tamoxifen-20mg /Day
endometrial malignancy
Raloxifene-60mg/Day
chemo / radiotherapy
Bazedoxifene-20mg/Day
follow up as
Ospemifene-60mg/Day
recommended]
Tab. Tranexamic Acid
500 mg
Combined
Oral
*
Contraceptive
• Iron (Oral] 60 mg
elemental iron /day
•
Parenteral Iron
(20mg/ml, total dose of
lOOmg/day)
•
L
Inj.GnRH analogues
(Gonadotropin
Releasing Hormone]
27
•
RS
Tab Ulipristal (As
Contraceptive30mg/Day and non
contraceptive5 mg/Day)
«\ J
28
_______ 2. Abnormal Vaginal Discharge ± Pelvic pain ± Backache
Community ASHA/MAS.
Distribution of Oral Iron, Calcium with D3 tablets and condoms.
/ Sub Health
Ensure follow up to check for resolution of Infective vaginal
Centre
discharge / acute PIP. Encourage treatment of the partner.___________
HWC/
CHO
•
Kit-1,2,6
Hb
MO
Primary
•
Condoms
VDRL/HBsAg/HIV
Health
•
Injectable
VIA
IfCHOisa
Centre
Ceftriaxone
ftv lady, provide
c
•
Tab Calcium ±Vit D
follow up care
•
Iron (Oral) (60mg
in subsequent
elemental iron/Day)
visits to
•
Parenteral Iron if
women who
needed
have taken
•
(20mg/mI, total
initial care at
dose of lOOmg/Day)
<' ■' ■ > ft®?
higher level.
■
| History and
| examination
including per
speculum and
bimanual
examination
Ensure
treatment of
partner
■
—
-
-
.
■
Gynaecologis
t
Commi
Health
’* •
h ih FP1 ■>
/
■
Tertia)
4^
______________-■
.
•
Kit-1,2,6
•
Condoms
•
Inj. Cefotaxime
(lgm/12 hourly and can
be extended up to 2gm/12
hourly) /Cefoperazone
•
Inj. Metronidazole
•
Inj. Clindamycin
•
Tab Calcium ±Vit D
•
Iron (Oral)
• Parenteral Iron
• Treatment of partner
J
Hb
J
VDRL/HBsAg/HIV
S
Vaginal discharge
examination (Hanging
drop and Gram stain)
J
USG
J
VIA
S Pap smear
S
Colposcopy, SOS
biopsy
S
LLETZfLarge loop
Excision of the
Transformation Zone)
S Cryotherapy
S Thermocoagulation
29
______ 3. Prolapse
Community ASHA/MASand ANM:
S
Lifestyle modification, healthy diet, smoking cessation.
S
Early treatment for chronic cough and constipation.
S
Promote institutional delivery for proper intra-natal care.
S
Reinforce need for postnatal exercises
S
Explain Kegel's exercises for early prolapse.____________
CHO
•
Lifestyle
MO
modification
c/
■.i®
•
1st and 2nd degree
Prtaai,
prolapse - Pelvic floor
exercises
•
Pessary insertion if
c
necessary by MO or SN
after tele-consultation
with Gynaecologist
•
Physiotherapy for
backache
StS/HW
SUh
w
ty
on
..
0^
if
c
ft
/
c n,ICa'
■
■
I
Gynaecologis
t
•
Lifestyle modification
1stand 2nd degree Pelvic floor exercises
• 3rd degree - Pessary /
Surgical intervention
( VH with Me Call's
with AP repair OR
conservative surgery if
lady wants to preserve
childbearing or is < 40
years of age]
• Surgical management
of Vault prolapse and
associated Stress
Urinary Incontinence
• Physiotherapy for
backache
USG
■
30
4. Lower Abdominal Pain
Community ASHA/MAS:
Distribution of Oral Iron and Calcium with D3 tabs
I Sub Health •
Centre
•
Deworming
•
IEC for prevention of diarrhoeal diseases
•
Counselling regarding Partner treatment for PIP
S
Urine routine
Kits-1,2,6
CHO
«wc/
and
microscopy
Condoms
MO
Primary
it
S
Stool
Refer
to
Health
Tab Calcium ±Vit
examination
Gynaecologist if
D
?
■
no
•
Injectable
response to
antibiotics (Cefotaxime)
z
treatmentor
•
Tab
S
relapse of Metronidazole
3 symptoms within •
Iron (Oral)
■'ll
£ 6 months or
• Parenteral Iron
S
if
associated with
fever/ vomiting/
abdominal
distension/
. breathing
difficulty/
abdominal
lump/TB in
If patient or a
I family member/
within 6 weeks of
1
delivery or within
a month of
abortion
______
___________
USG
•
Kit-1,2,6
Gynaecologist
Urine
routine
•
Condoms
»ealth
and microscopy
•
Inj. Cefotaxime
Centre
S Stool examination
/Cefoperazone
subfii.
GI endoscopy
•
Inj. Metronidazole S
S
Laparoscopy
•
Inj. Clindamycin
and SOS surgical
•
Tab Calcium ±Vit
intervention
I ertiarv^"' '■ ■
D
•
Iron (Oral)
• Parenteral Iron
College
• ATT for genital TB
Sih
■..
K-
_____
31
5 Abnormal/ Unhealthy cervix
Community ASHA/ANM/MAS: "
Warning symptoms suggestive of cervical cancer.
/ Sub Health Z
Z
Importance of screening for cervical cancer.
Centre
Z
Protective effect of condoms on Cervical Intra-epithelial lesions.
Z
Safe sex practices
____________________
VIA
CHO
HWC/
PAP Smear
MO
■
?:„«/uph
sfe
Heaitm
ton
Ho
Hbspita
Care
fe
Wi
««
S: 'a "
Gynaecologist
VIA
Pap smear
Cervical biopsy
(may be sent to higher
centre for reporting)
S HPV testing
S
Colposcopy
S
Cervical biopsy
(may be sent to higher
centre for reporting)
Z
LEEP, LLETZ,
Cryosurgery
Z
Management of
Cervical cancer
(Surgery or
Radiotherapy)
33
6 Post hysterectomy follow up of woman who had Hysterectomy before 45 years
o age________
Community | ASHA/MAS:
+ Sub
Distribution of oral Iron and Calcium with D3
Health
S
IEC about Post-menopausal problems and care.
Centre______ S
Counselling on important of regular exercise and healthy diet.
HWC/.
CHO
• Hb
•
Tab Calcium ±
MO
VitD
• Lipid Profile
FRulc
•
Iron (Oral)
• S. creatinine
•
Parenteral Iron
• Vaginal Estrogen
creams
after tele-consultation
with the Gynaecologist
Communifv Gynaecologist
•
Tab Calcium ±
• USG
VitD
• Hb
•
Iron (Oral)
• Thyroid Profile
•
Parenteral Iron • Lipid Profile
pital
• Vaginal Estrogen
• S. creatinine
trict
creams
• ECG
• Oral Estrogen • Bone Mineral Density
iary;,' |
Progesterone for
ir’.’S
testing
HRT if indicated
MH
.
• Bisphosphonates
College
• Tab Tibolone
(2.5mg/day)
I
iO" i'*
:
J
34
Annexure 2
Basic Facts on Hysterectomy
About Hysterectomy
Uterus is a midline pelvic organ of the female reproductive system where the fetus
develops during pregnancy. The surgical procedure of removal of the uterus is called
hysterectomy. Hysterectomy is a major surgery done by a trained gynaecologist under
regional or general anaesthesia. An abdominal hysterectomy involves removal of the
uterus through an incision in the lower abdomen. When hysterectomy is performed
through an incision in vagina it is called a vaginal hysterectomy. Laproscopic
Hysterectomy is where the uterus and cervix are removed completely with the help of
laproscope & laprosopic instruments through small incisions on the abdomen.
•
•
A total hysterectomy is the removal of the uterus and cervix.
When a hysterectomy includes removal of both the ovaries and fallopian tubes,
the procedure is called hysterectomy with Bilateral Salpingo-Oophorectomy.
Hysterectomy with or without Oophorectomy
The various indications for ovarian removal at the time of hysterectomy include genital
tract malignancies (ovarian cancer, uterine cancer, cervical cancer, metastasis from
non-genital tract malignancies), removal of ovaries and tubes in women genetically
susceptible to ovarian cancer, ectopic pregnancy, ovarian abscess, ovarian
endometriosis etc. In many non-cancerous conditions oophorectomy is performed with
the aim of reducing the possibility of ovarian cancer in the future. Risk, benefits, and
alternatives need to be discussed with the patient before surgery. Patients must be
informed of the possible complications and the long-term effects of decreased hormone
levels due to ovarian removal.
Unnecessary hysterectomy
There is a fear that hysterectomy is done without reason. Patients can seek more
than one opinion before taking decision. Many gynaecological conditions can be
managed conservatively without the need for surgical intervention and hysterectomy
should always be reserved as the last option. Few cases where hysterectomies can be
avoided are
• Abnormal uterine bleeding
• Fibroid
• Completion of family
• Precondition for employment
35
Fear of cancer
Hysterectomy as a method of treatment
Hysterectomy can be performed in various conditions such as treatment of uterine
cancer, ovarian cancer, some cases of cervical cancer, and various common
noncancerous gynaecological conditions like abnormal uterine bleeding, fibroids,
adenomyosis, endometriosis, uterovaginal prolapse, chronic pelvic pain etc. that lead to
varying levels of pain, discomfort, uterine bleeding and emotional stress amongst
women. A hysterectomy is a major operation with a long recovery time and is only
considered after less invasive treatments have been tried. Although hysterectomy is
often the definitive treatment for many gynaecological conditions, nonsurgical
alternatives should always be attempted in elective cases.
Conditions for which hysterectomy can be done after all nonsurgical options have
been tried
a. Uterine fibroids (lumps in uterus] that cause pain, bleeding or other problems
b. Thickening of the uterus - adenomyosis, endometrial hyperplasia etc.
c. Uterine prolapse, which is a slidingof the uterus from its normal position into the
vaginal canal
d. Cancer of the uterus, cervix, or ovaries
e. Abnormal vaginal bleeding*
f. Chronic pelvic pain
A hysterectomy may not be the best option for all women. It shouldn’t be
performed on women who still want to have children unless no other alternative
are possible. Luckily, many conditions that can be treated with a hysterectomy
may also be treated in other ways. For instance, hormone therapy can be used to
treat endometriosis. Fibroids can be treated with other types of surgery that
spare the uterus.
Hysterectomy should always be the last option.
Complications and Side effects
•
Immediate Complications include heavy bleeding during or after
surgery, risk of blood transfusion, damage to surrounding organs and
blood vessels like the bladder, urethra, uterine artery and nerves,
blood clots in the legs and lungs, breathing problems or problems due
to anaesthesia
• Short term-fevers and chills, persistent nausea and vomiting, infection
at the incision site, excessive bleeding, requirement of blood
transfusion, difficulty with bowel function, difficulty voiding, pain
which is not resolving, Injury to adjacent organs (bowel, bladder,
ureter], Injury to nerves, chest pain, difficulty breathing, lower
extremity, or calf pain and anesthesia related complications.
36
•
Long-term- Bladder dysfunction due to cystocele formation (bladder
prolapse through the vaginal wall), stress incontinence (Involuntary
passage of urine), formation of enterocele and rectocele (bowel and
rectum prolapsing through the vaginal wall), vaginal vault prolapse.
•
Long term effects of decreased hormone levels- surgically induced
menopause including hot flashes (sudden feeling of warmth in the
upper body which is usually most intense over the face, neck and
chest), night sweats, insomnia, vaginal dryness, recurrent UTI, mood
changes, irritability, increased bone loss leading to osteoporosis and
cardiac disease.
Changes women can expect after a hysterectomy
•
The women attains a surgical menopause so there will be no menstrual
periods.If the ovaries have been removed along with a hysterectomy,
there may be menopausal symptoms like hot flashes, sweating, vaginal
dryness, mood swings etc as well as increased chances of developing
osteoporosis, dyslipidemia, cardiovascular diseases, stroke etc.
•
If ovaries are retained, menopause is experienced at a younger than
average age.
•
There will be a symptomatic relief of symptoms.
•
Some women may experience mood changes after hysterectomy. There
may be grief and possibly depression over the loss of fertility, loss of
interest in food & lethargy.
•
Some women have vaginal dryness or lack of interest in sex after a
hysterectomy, especially if the ovaries have been removed.
•
If both ovaries are removed, this may put the woman at higher risk for
certain conditions such as: bone loss, heart disease, and urinary
incontinence (leaking of urine) 1.
Issues relating to menstruation
Menstruation is required to be managed in a healthy and hygienic manner. One of the
huge challenges in our society is the inability to deal with blood flow hygienically during
menstruation.A large number of hysterectomies are done to get rid of menstruation
without application of safer medical methods of treatment. Here, good counselling by a
provider and a trained counsellor becomes very important. ASHA, Anganwadi worker
and ANM can all popularize this by using a campaign format.
37
Annexure 3
Guidance on Conducting Audits of Hysterectomies
Medical audits are utilised to monitor the appropriate use of specific procedures. In the
case of hysterectomy, ensuring regular audits may be necessary in areas where
unnecessary use is suspected. The guidance below explains the process and use for an
audit.
Who should conduct the assessment?
Setting up of a Hysterectomy Audit Committee - Medical audit is best conducted by more
than one person e.g. a technical expert and someone with social sciences expertise. A
guideline for practitioners will help them to provide services that are ethically and
technically correct in the social setting in which the patient exists and practitioner
practices.
What can form part of the audit for unnecessary hysterectomy?
1. Patient Profile
a. Age
b. Number of living children
c. Socio economic status
d. Education
e. Cultural beliefs
f. Occupation
g. Area of residence
h. Distance from hospital
2. Eligibility of patients for hysterectomy
• Is the indication for hysterectomy matching with the signs and symptoms of the
actual disease from history taking, clinical examination, pathological and
•
•
radiological findings?
Is the patient really eligible for hysterectomy - age group, cause, menstrual
symptoms marital status, desirous of fertility etc.
Is the patient prepared for anaesthesia and hysterectomy - medically and
psychological fit?
3. Use of alternative and effective medical treatment
• If the condition was benign (not cancer), were alternative non-surgical / medical
treatments tried
• Was counselling on alternative treatment modalities done
• What was the alternative treatment provided and for how long was it used e.g.
Polyp : Polypectomy
Adenomyosis : LNG lUS/Oral hormonal therapy/Others
• Leiomyoma - Myomectomy/Hysteroscopic resection/Uterine artery
39
embolization/GnRH analogues / Ulipristal acetate /Inj. DMPA/LNG IUS
Endometrial Hyperplasia - High dose Progesterone
GIN: Conization/LEEP/LLETZ
Treatment of Coagulopathy
AUB due to Ovulatory dysfunction: Progesterone therapy
Utero-vaginal prolapse - Pessary
Obstetrical Haemorrhage : Uterine artery embolization/ Compression
sutures/ Uterine balloon tamponade
• Was the effectiveness of alternative treatment assessed before deciding on
hysterectomy
• If yes, was it documented in the patient's case notes with necessary supportive
documents
4. Choice of surgical method
• What was the rationale for selecting the type of surgical procedure
• Was the patient made aware about risks and outcomes of the selected
procedure?
• Was comparison of costs of recommended procedures done - abdominal, vaginal
and laparoscopic hysterectomy?
5. Ethical issues
• Was the decision on selecting the treatment method, particularly if a surgical
procedure was recommended, based on involved and informed consent of the
patient
• Was primary care for the gynaecological condition available to the patient
• Was choice of second or expert opinion available to the patient
• Was there any conflict of interest by the provider i.e. was provider opinion
influenced by personal interest e.g. learning more about a procedure (training
situations) or earning monetary benefit from patient or insurance agency
• Whether the audit is interfering with professional freedom of the practitioner or
with doctor patient relationship in that particular setting
6. How was the Hysterectomy conducted?
Was it performed abdominally, vaginally or laparoscopically?
Approach will depend on indications for surgery, nature of disease, surgeon and
patient preferences
7. Why was the hysterectomy conducted?
The reasons can range from benign conditions of the uterus to malignancies of
the genital tract as well as obstetric reasons
Common Gynaecological Reasons
40
• Uterine fibroids - depends on site, size and symptom
• Chronic pelvic infection
• Chronic pelvic pain
• Abnormal Uterine Bleeding:
• Polyps
• Adenomyosis, endometriosis
• Endometrial causes - Malignancy, Hyperplasia and other
• Cancer of the ovaries, cervix, fallopian tubes.
• Premalignant lesions of cervix.
• Iatrogenic
• Utero-vaginal prolapse
Obstetric Reasons
• Atonic Post-partum Haemorrhage with/without Placenta praevia
• Traumatic Post-Partum Haemorrhage
• Adherent placenta with/without Placenta praevia
• Sepsis
• Rupture Uterus
• Intractable post-partum haemorrhage
8. Were there intra-operative or post-operative complications during/following
hysterectomy and were these documented?
9. Was there need for correction of anaemia by blood transfusion/ parenteral iron?
10. Was the Hysterectomy covered by an insurance scheme?
11. What was the cost incurred due to hysterectomy, including related
interventions/treatment before, during and after the procedure?
41
Annexure 4
VARIOUS MODALITIES OF TREATMENT AVAILABLE FOR AUB/ DUB
1. Medical treatment for dysfunctional uterine bleeding
Medical treatment options for DUB include tranexamic acid, nonsteroidal anti
inflammatory drugs (NSAIDs), combined oral contraception pill, progestogen, danazol
and gonadotropin-releasing hormone analogues (GnRH-a). The effectiveness of the
reported medical therapy for DUB has been evaluated and reviewed in systematic
reviews in the Cochrane Library.
Tranexamic acid
Antifibrinolytic tranexamic acid has proven to be more effective than placebo, NSAIDs,
progestogen in the luteal phase of menstrual cycle, or ethamsylate when subscribed to
women with DUB, without any serious adverse effects . A reduction in menstrual flow by
34-59% has been reported by Wellington and Wagstaff , which is quite impressive.
However, this drug is mainly indicated for acute or short-term use and not as a definite
treatment for DUB.
The main problem with the administration of tranexamic acid for the treatment of DUB
is the potential risk of thromboembolic disease due to its antifibrinolytic effect. Although
this is always an issue, especially in cases of severe anemia, it seems that the risk does
not reach a statistical significance.
Nonsteroidal anti-inflammatory drugs
Prostaglandins are found in high concentrations in the endometrial shedding.
Nonsteroidal anti-inflammatory drugs inhibit prostaglandin synthesis and decrease
menstrual blood loss. NSAIDs are quite effective in cases of DUB compared to placebo,
but they are less effective than either tranexamic acid, danazol, or levonorgestrel
intrauterine system.
Combined oral contraceptive pill
The combined oral contraceptive pill is another effective alternative treatment for DUB,
offering at the same time contraception to women. It reduces menstrual blood loss, but
there are not enough data to determine its value in comparison to other drugs . So, it
seems reasonable to offer a combined oral contraceptive pill [COC] in young women
suffering from DUB who also seek for contraception at the same time.
42
Progestogens
The administration of progestogens for the treatment of anovulatory DUB was always a
tempting alternative for physicians, in order to restore the natural cycle of endometrial
growth and shedding. The oral luteal phase progestogens do not seem to be more
advantageous over other hormonal medical treatments or levonorgestrel-releasing
intrauterine device. A long-term administration of progestogen is sometimes followed by
severe side effects, such as water retention and hirsutism, depending on the type anddose
of progestin.
Danazol-gonadotropin-releasing hormone analogues
Danazol and the GnRH analogues were found as highly effective agents for DUB compared
to other medical treatments . However, the administration of danazol or GnRH-a is
limited due to their strong side effects. Long-term administration of danazol may cause
hirsutism while GnRH-a is associated with irreversible bone loss when used for more
than 6 months. Thus, their utility is restricted mainly for short-term use, especially in
cases of severe anemia, until further treatment is decided.
2. Levonorgestrel-releasing intrauterine device
Another medical method for the treatment of DUB is the levonorgestrel-releasing
intrauterine system (Mirena®). It was originally developed as a contraceptive method ,
but it has been proven quite effective in the treatment of DUB, so the device acquired
approval for that indication too.
Its efficacy is based on the continuous local release of the progestogen (levonorgestrel)
within the uterine cavity, which suppresses endometrial growth. Studies report
reduction of blood loss in menstrual cycles up to 97%, with its maximum efficacy 1 year
after insertion. The majority of women with Mirena bleed only for 1 day or experience
just spotting during their period, while 15% of them become amenorrhoeic.
There are two trials comparing levonorgestrel intrauterine device (IUD) with medical
treatment, two trials to transcervical resection of the endometrium and three trials
comparing Mirena® with balloon ablation. Mirena was found superior to cyclical
progestogens and mefenamic acid, but is significantly less effective than endometrial
ablation in reducing blood loss. Interestingly, levonorgestrel IUD was found more cost
effective than hysterectomy in Hurskainen et al.'s trial.
3, Surgical treatment for dysfunctional uterine bleeding
In cases of DUB resistant to medical treatment, physicians should offer to women an
alternative surgical treatment. In such patients, one could choose between endometrial
ablation techniques and hysterectomy, taking into consideration patient's age, physical
condition, and will.
43
Dilatation and curettage, which is offered as an alternative treatment option in women
with excessive blood loss during menstrual periods, results in a temporary reduction of
blood loss for the first month after the procedure, therefore it should not be proposed
and performed in women suffering from DUB.
Endometrial ablation techniques
Since Ashermann in 1948 described for the first time the association between
amenorrhea and dilatation and curettage for termination of pregnancies, several
investigators have studied the possibility of a controlled destruction of the basal layer of
the endometrium in order to treat abnormal uterine bleeding.
Several methods have been developed from the early 1980s for the ablation of the
endometrium and have been studied in cohort studies and randomized controlled trials.
Basically, all these methods are divided in two large groups with a criterion, the need of
direct visualization of the endometrial cavity.
First-generation endometrial ablation techniques
First-generation endometrial ablation techniques are based on direct visualization of
the endometrial cavity with a hysteroscope. Three methods were developed since the late
1980s, and their efficacy were studied and compared to other techniques by many
investigators. Before the application of each technique, endometrial thinning was
necessary by using GnRH-a or danazol.
Hysteroscopic laser ablation
The first laser method was a neodymium-YAG laser, which destroyed the endometrium
through a hysteroscope . Observational studies have reported a satisfaction rate up to
97% and amenorrhea rates ranging between 25% and 60% after hysteroscopic laser
ablation (HLA). Failure rates varied between 7% and 21% in the same studies. There is
only one prospective randomized trial comparing laser ablation with transcervical
resection of the endometrium reporting 23% amenorrhea rate and 90% satisfaction rate.
Despite the promising results of its use, the equipment's high cost and extended learning
curve remain obstacles for its wide application.
Transcervical endometrial resection
The wide use of a resectoscope in gynaecological operations allowed its application as a
method for treatment of DUB . Transcervical endometrial resection (TCRE) has been
shown to be an effective and safe method for treating DUB . TCRE was tested in
nonrandomized prospective studies, which reported a satisfaction rate between 85% and
87% and an amenorrhea rate varying up to 46%. TCRE is comparable to other
hysteroscopic endometrial ablation techniques in terms of amenorrhea and satisfaction
rates. Direct visualization of the endometrial cavity and the possibility of treating
concomitant endometrial pathology at the time of endometrial ablation remain themajor
advantages of the method.
Rollerball endometrial ablation
44
The technique was developed in 1989 in Australia by Vancaillie and soon became quite
J„hX
relative"Simplicity and exceiient results.
results from its application to the other two first-generation ablation ^hniqu
fsatisfaction rate up to 94% and amenorrhea rate varying between 29/o and 35/o).
XrS endometrial ablation requires less operative time and shorter learning curve
compared to TCRE and HLA.
HLA and roderbah ab.ahon are
encephalopathy with cerebral edema.
Second-generation endometrial ablation techniques
Many endometrial ablation devices have been developed m, the
treatment of DUB and categorized as second-generatm
‘’’^"heYr
of 1 dllect
xxxxre^
prior to ablation is a mandatory prerequisite.
Every method consists of a different device tvhldn hr
bipolar energy, ultrasound, microwaves, hea 1 g
. requ|re less skills of the
selective destruction of the e"do"etr‘al X'JaSng curve is smaller. The operation
ZZXSXX can beLe minima,, and the eomphcationrate
is reduced.
..............
Thermal balloon endometrial ablation
.
r haiinnn
balloon for
for insertion
insertion in
in the endometrial cavity and a
Xtn XTnTeX the balloon is filled with hot liquid that causes a destructive
thermal effect to the surrounding endometrium.
-- ■’ ! was developed in 2004, and since then, various authors
The Thermablate thermal balloon
studied the application results of this d-i'=%"“5h,“ ra‘e
have
22.2% and 35% with a failure rate varying between 3 /o and 5.
.
Endometrial ablation by hysterosoopic instillation ot hot saline (hydrotherm
ablator)
45
This technique, although applied hysteroscopically, is categorized as a secondgeneration endometrial ablation technique. Externally heated saline of 90°C is infused
into the uterine cavity through the external sheath of a diagnostic hysteroscope. The
pressure used for the infusion is less than 45 mmHg, thus preventing flow through the
fallopian tubes. Under direct hysteroscopic view, the hot saline causes ablation of the
endometrium. The application experience of the method is tested in several
observational studies and in one randomized controlled trial compared to rollerball.
Amenorrhea rates are reported up to 53%, cure rate up to 94%, and satisfaction rate up
to 98%.
Microwave endometrial ablation (MEA)
The microwave endometrial ablation system has been compared to first-generation
ablative techniques (TCRE and rollerball) in randomized trials with similar results in
terms of amenorrhea and satisfaction rates, even 10 years following surgery with low
complication rates. There is also one randomized controlled trial comparing MEA and
thermal balloon ablation, showing similar results in relation to menstrual scores and
satisfaction.
Endometrial laser intrauterine thermal therapy (ELITT)
The technique was developed by Donnez et al. in 1996 and causes endometrial ablation
by laser photocoagulation . Preparation of the endometrium prior to laser application is
considered necessary. The technique has been evaluated in a prospective observational
study. Satisfaction rate was reported up to 90% at 12 months after treatment, while
amenorrhea rate was 71% . There is only one randomized controlled trial comparing
ELITT and TCRE, reporting at 12 months amenorrhea rates of 56% and 23%, respectively
Cryo-endometrial ablation
Endometrial ablation is achieved by a cooling gas, which achieves a temperature of -90
to -100°C within the endometrial cavity. The treatment has been evaluated in
prospective observational studies with encouraging results (amenorrhea 28% and
satisfaction up to 91%) .
Bipolar impedance controlled endometrial ablation (Novasure)
The device consists of a radio frequency generator and a single-use bipolar ablation
probe. The probe consists of a three-dimensional expandable bipolar electrode, which
comes in touch with the entire endometrial cavity, when opened. There is also a vacuum
pump within the generator, which provides continuous suction of the endometrial lining
and debris; therefore, preoperative preparation of the endometrium is not generally
needed. The generator operates at 500 KHz and has a power cutoff limit of50 fl of
tissue impedance. Once the myometrial layer is reached, immediately the tissue
impedance increases to 50 fl, and the generator automatically switches off.
This method has been evaluated in prospective observational studies and women
reported a satisfaction rate of up to 87%, an amenorrhea rate of up to 58%, and a failure
rate of up to 3% 1 year after treatment, while amenorrhea rate at 3 years postablation
46
. , .o
/r0/A At S vears following treatment, women report an impressive
X* 75£ —U -a. an nveraH ~»be
98% There is one clinical trial comparing Novasure with combmed loop excismn plus
X S Xon, reporting an amenorrhea rate of 41% and a sa.isfaen.n ra« 93%
in .he Novasure arm, compared with 35% and 94%,
" Xis
other
Novasure has been compared in prospective randomized controlled trials with
second-generation ablation techniques.
47
Hysterectomy in Karnataka
Patterns
►rwatecce of hysterectomy among women aged 40-49 (NFHS-51
The National Family Health Surveys Rounds 4 (2015-16) and
5 (2019-21) consistently find moderately high prevalence of
hysterectomy in Karnataka.
•
One in eleven women who are currently 40-49 have had a
hysterectomy; they underwent the surgery at a median
age of 36.
•
Prevalence amongst women in the 30-39 age group
shows small reductions over the past two survey rounds,
which may suggest some declines.
•
Prevalence varies across the state, with up
to 1 in 4 women (40-49 yrs) reporting previous
hysterectomy in several districts.
'few
•
About
55%
of
hysterectomies
conducted in private facilities.
■
are
•
The leading self-reported causes by women
are
excessive
menstrual
bleeding,
cervical
discharge and fibroids/ cysts.
klM
.J
:
,1 i (■ «*|
•
Rural, less educated women have higher
odds of hysterectomy - which indicates concerns
with vulnerability and equitable access to quality
health care.
M'dpiri.k'cKi- >1. JO H!
WtChpwafFVi- (109, M Ji
Health Risks
•
Hysterectomy, even without oophorectomy, is correlated with long term health risks,
especially in women who undergo the surgery before 40 years.
•
An analysis of the Longitudinal Survey on Ageing in Inda found correlations with risk of
hypertension, high cholesterol, diabetes and bone disease amongst older women.
Key Concerns
• /Access to treatment for gynaecological morbidities - do women have access to hormonal
treatment, LNG-IUS and other medical options? Are there outreach and cost barriers?
•
Who is conducting unindicated hysterectomies? How can the national guidelines support
better monitoring and auditing?
•
Prevention through outreach, communication, cancer screening and better access to
gynaecological care
•
Consequences on women’s health for the large number of women who have already
undergone hysterectomy, especially with ovarian removal.
Union Health Ministry Guidelines
•
The Union Health Ministry in 2023 issued guidelines to prevent unnecessary hysterectomies
(enclosed) provide:
o
o
o
3
Guidance to public health programme managers on measures to address
unnecessary hysterectomy at the facility level
Strategies for monitoring and community awareness generation activities
Clinical guidelines on common conditions that have emerged as indications
Audit and data collection forms
•
Treatment protocols for dysfunctional/abnormal uterine bleeding, fibroids, cysts, uterine
prolapse and abnormal cervix are proposed and undergoing further development with
FOGSI and other experts.
•
The Guidelines call for setting up district, State-level and national hysterectomy monitoring
committees to collect and review data on age, indications, who conducted the procedure
and processes followed (data format enclosed).
•
State and district committees are to collect data including a monthly audit, at the district
level, of cases with following indications:
•
Hysterectomy with/ without BSO in women <35 yrs. of age
•
Hysterectomy with BSO in women < 40 yrs. of age
• All cases where no indication for doing the procedure is mentioned in the records
• All cases where no records of treatment prior to hysterectomy (in papers or in
history) are available
•
Discrepancy between mentioned indication and HPE report
•
Any severe morbidity/mortality due to hysterectomy
Key information to communicate through health awareness programmes:
• Hysterectomy should not the first treatment option for most gynaecological morbidity: have
alternative treatments been tried?
•
Ensure examination and lab tests with qualified gynaecologist
•
Know the extent of surgery: will ovaries be removed?
•
Second opinion is essential
•
Know the side effects, especially for women <40 years
BECAUSE OF ME
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building community health
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JLrayas
ROUNDTABLE
"Access to Rational Treatment for Gynaecological Morbidities
& Prevention of Unnecessary Hysterectomies in Karnataka"
18th December 2023
VENUE: St. John’s Medical College (SJMC),
Sarjapur Road, Bengaluru, Karnataka
PROGRAMME SCHEDULE_____________
Time_________
Session details_________________________ ____________
12.30 pm -1:30 pm
LUNCH- Banyan Tree
REGISTRATIONS Cardinal Gracious Hall, Ground Floor, SJMC_________
Welcome: Dr. Shashikala Karanth, Professor & HOD Dept of OBG SJMCH
Director, St. John's National Academy of Health Sciences; Rev. Fr. Jesudoss
Rajamanickman
Dean, St. John's Medical College, Dr. George Dsouza
Dr. Ravindranath Meti, District Health Officer, Bengaluru Urban
Other Dignitaries
Background and Overview of the Roundtable
Dr. Narendra Gupta, Prayas
1:30 pm - 1:50 pm
1:50 pm - 2:00 pm
2:00 pm - 2:05 pm
2.05 pm - 2.20 pm
Human Dignity & Integrity of Body Parts
Rev. Dr. J. Chales Davis Associate Director SJMC
National Campaign on Preventing Unnecessary Hysterectomies - a
FOGS! initiative
Dr, Hema Divakar, Former FOGSI President
2:20 pm - 2:35 pm
Preserve the Uterus: Awareness and improving gynecological care
and prevention of unnecessary hysterectomies.
Dr. Shashikala Karanth, Professor & HOD Dept of OBG SJMCH
2:35 pm - 2:45 pm
Public Health and Women's Health Perspectives
- Dr. Thelma Narayan, SOCHARA
2:45 pm - 3.00 pm
Presentation on trends in hysterectomy in Karnataka
- Dr. Sapna Desai, Senior Fellow Population Council Institute, New
Delhi and Member National Subcommittee on IEC and
Alternative Treatments for Hysterectomy
3.00 pm - 3:15 pm
National Guidelines for Preventing Unnecessary Hysterectomies.
Dr. Amita Bali Vohra, DDG, DGHS, MoHFW, Govt, of India
3:15 pm - 03:25 pm
Data Driven Mentorship Program for Reduction of Unnecessary
Hysterectomies
- Dr. P S Balu, Chitradurga
________
Young Voices - To prevent unnecessary hysterectomies.
Senior Residents / PG SJMCH
3.25pm - 3.35pm
3:35 pm - 3:50 pm
TEA BREAK & PHOTO SESSION
3:50 pm-4:50 pm
Open discussion on implementation of national guidelines to prevent
unnecessary hysterectomies. (Small group discussions)
Moderators:
Dr. Shashikala Karanth, Professor & HOD, Dept of OBG SJMCH
Dr. Vishnupriya KMN, Associate Professor, Dept of OBG SJMCH
Vote of thanks
Dr. Madhu Swetha Sharma
xycj nffcin
TcTbP-ZJ TTci
2023 INDIA
cThRUTH
Government of India
Department of Health and Family Welfare
Ministry of Health and Family Welfare
TErlTT
RAJESH BHUSHAN, IAS
SECRETARY
’Snjcf
D.O.NO.H.11016/07/2Q22-MH-I
28-4-2023
The mafrer is regarding prevention of unnecessary and often
unjustified hysterectomies performed by certain medical institutions.
This issue is being closely monitored by Ministry of Health and Family
Welfare. Guidelines in this regard were prepared by this Ministry and the
copy of the same with a data collection format was circulated earlier to
all States/UTs. The copy of the guidelines is again enclosed herewith
along with data collection format.
The States are requested to share the hysterectomy status/data
Pre and Post implementation of these guidelines. They are also advised
to undertake compulsory audits for all hysterectomies, as is already being
done for maternal mortality in all healthcare Institutions (both public and
private).
rs sincerely,
Ends.: as above
(Rajesh Bhushan)
ACS/Principal Secretary/ Secretary (Health) of States/UTs
Room No. 156, A-Wing, Nirman Bhawan, New Delhi-110 011
Tele : (0) 011-23061863, 23063221, Fax : 011-23061252, E-mail: secyhfw@nic.in
- Media
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