Hysterosalpingogram the patients perspective
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Hysterosalpingogram- the patients perspective. Maggie Williams Clinical Lead Nurse Radiology Gateshead Health NHSF Trust. Hysterosalpingogram. Outpatient procedure Varying levels of importance Doctor who is free, radiology/gynaecology consultant, specialist nurse.

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Hysterosalpingogram the patients perspective l.jpg
Hysterosalpingogram- the patients perspective

Maggie Williams

Clinical Lead Nurse Radiology

Gateshead Health NHSF Trust

Hysterosalpingogram l.jpg

  • Outpatient procedure

  • Varying levels of importance

  • Doctor who is free, radiology/gynaecology consultant, specialist nurse.

  • Fitted in around other procedures.

Patients experience before appointment l.jpg
Patients experience before appointment

  • 18 months to 2 years infertility.

  • Highly emotional

  • Referred via GP

  • Gynaecology OPD

  • Referral for HSG

Following referral for hsg l.jpg
Following referral for HSG

  • Written information leaflet

  • Verbal information at Gynae OPD

  • Letter asking to telephone for appointment on first day of menstrual cycle.

How well does this prepare our patients l.jpg
How well does this prepare our patients?

  • Still asked:

  • Where do you put the injection?

  • How do you get the dye into my tubes?

  • Do I have to take my pants off?

  • Will it hurt?

  • My friend says it is awful.

Slide6 l.jpg

This made us think:

Are we preparing our patients well enough?

What do our patients want from us?

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We decided to investigate

2 areas:

  • Women’s perception of pain

  • Women's expectations and emotions around time of HSG

Perception of pain l.jpg
Perception of Pain

Audit of

  • Pain during the HSG

  • Type and length of pain

Patient audit l.jpg
Patient audit

  • 60 patients asked to complete and return questionnaire

  • 45 responses

Results type of pain l.jpg
ResultsType of Pain(%)

Results cont duration of pain l.jpg
Results (cont) Duration of Pain

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Results (cont)Pain Score(%)

Summary l.jpg

  • The majority of patients experienced crampy pain for the duration of HSG.

  • A smaller but significant number of patients had pain for length of time after HSG

  • Majority of patients had pain score of 5

    or more.

Changes l.jpg

Amended patient information leaflet to advise patients to take simple analgesia prior to procedure.

Re audited patients.

Second audit l.jpg
Second audit.

Same audit with additional questions:

  • Did you take any painkillers before the HSG?

  • What type of painkillers?

  • 35 responses.

Results type of pain16 l.jpg
ResultsType of Pain (%)

Results cont duration of pain17 l.jpg
Results (cont) Duration of Pain

Results cont pain score18 l.jpg
Results (cont)Pain Score (%)

Summary of results l.jpg
Summary of results

  • 68% of patients took analgesia prior to HSG examination

  • 97% of patients still experienced pain during or after HSG.

  • 34% during HSG only

  • 34% for a couple of hours, but

  • 20% for a number of days after.

Summary of results cont l.jpg
Summary of results (cont)

  • 82% of original group and 80% of second group scored pain 5 or higher

  • Pain scores of those who hadn’t taken analgesia ranged from 2-10.

  • Were mainly towards higher end of scale.

  • Use of simple analgesia in this group had little effect on pain scores.

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Summary of results (cont)

  • Women who took simple analgesia prior to HSG seemed to have little benefit.

  • Pain scores 80% 5 or more

  • This did not correlate with our perception of patient pain

Other studies l.jpg
Other studies

  • Duffy et al 2008:

  • Reviewed current practice in 104 UK centres.

  • 50% gave formal advice re pain relief

  • 35% offered no analgesia

  • Did not review the effect of analgesia

Women s emotions and expectations l.jpg
Women's emotions and expectations

We decided to progress our work to look at:

  • What are women's emotions and expectations of HSG?

  • Do we meet their needs?

Research study l.jpg
Research Study

  • Patients referred for HSG

  • Sub fertility

  • Referred from within Trust

Slide26 l.jpg

  • To inform our knowledge about the specific needs of this group of women.

  • Discover the underlying issues that women have at the start of sub fertility investigations

  • Raise awareness of the need of research by nurses in areas where they are practicing.

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Conclusion of literature review

  • High incidence of anxiety and depression in sub fertile women

  • Low incidence of qualitative studies addressing this situation

Method l.jpg

  • Qualitative study using grounded theory research

  • We used interviews and scheduled them prior to HSG

  • During interview we asked 12 Core questions allowing the women to expand their answers to each question

  • 10 Recorded Interviews: approx one to one and half hour duration.

Question categories l.jpg
Question Categories

  • Background to their sub fertility or

    their story

  • Expectations: pain, dignity, results.

  • Importance of HSG to them

  • Formal support from professionals

  • Informal support from families

A number of themes developed l.jpg
A number of themes developed

  • Written information does not meet all of the patients needs

  • Women see HSG as a defining moment

  • Sub fertility is still a taboo subject

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Written information does not meet all of women's needs.

  • Information giving is not as simple as often thought

  • Written information not always read and often produces additional questions

  • One woman said “I was horrified” after seeing the information leaflet

Written information does not meet all of women s needs cont l.jpg
Written information does not meet all of women's needs. (cont)

  • Verbal explanation needed to support written information

  • When asked “..do you have any questions” at an out patient appointment women do not know if they have any questions because they have not read the information leaflets

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Women see HSG as a defining moment (cont)

  • Women rated the importance of HSG between 8 and 10. 10 being the most important

  • Signpost to further treatment

  • Watershed moment

  • ‘No progress can be made without it’

Sub fertility a taboo subject l.jpg
Sub fertility- a taboo subject (cont)

  • Loss of well being

  • Loss of self confidence

  • Anticipatory grief at potential childlessness.

Sub fertility a taboo subject cont l.jpg
Sub fertility- a taboo subject (Cont) (cont)

  • Women found infertility hard to talk about.

  • ‘I don’t want to be the source of other peoples gossip’

Slide37 l.jpg

Anxiety permeated all (cont)


Conclusions directed towards

anxiety reduction

Implications for practice l.jpg
Implications for Practice (cont)

  • Recognition that written information meets only part of the information requirements of women.

  • Women need verbal support from professionals along with written material: this allows their specific needs to be addressed leading to an increased ability to cope and reduction in anxiety

Implications for practice39 l.jpg
Implications for Practice (cont)

  • The role of the Advanced Nurse Practitioner should be reviewed

  • Nurse Practitioners can take a lead

  • Nurse Practitioners can use their role to advance education and communication between all specialities involved in the sub fertility field

  • This would produce a seamless service

Implications for wider practice l.jpg
Implications for Wider Practice (cont)

  • Health care professionals should recognise that written information may not reduce patient anxiety levels – verbal support should be available to compliment the patient information leaflet.

  • Sub fertility should stop being a taboo subject.

  • Raising the profile of focus groups.

Overall conclusion l.jpg
Overall Conclusion (cont)

  • Women do find HSG painful

  • Do we offer effective analgesia?

  • Do we meet women's information needs?

  • Do we address women's anxieties?

  • Do we prepare HSG patients adequately?

References l.jpg
References (cont)

  • Duffy,JMN, Gaity A, Watson AJS (2008) Pain Relief during Hysterosalpingography: A national survey.Human Fertility 11(2) 119-121

  • Williams M, Green L & Roberts K (2010) Exploring the needs & expectations of women presenting for hysterosalpingogram: A qualitative study.

    Currently unpublished.