Outpatient visits for women with postmenopausal bleeding; What do we tell our patients? A Qualitative study

Outpatient visits for women with postmenopausal bleeding; What do we tell our patients? 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A Qualitative study Albertine J Vroom, Nehalennia van Hanegem, Henrica MJ Werner, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4873136/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 4 You are reading this latest preprint version Abstract Background Postmenopausal vaginal bleeding is a common complaint and requires diagnostic work-up to rule out endometrial cancer. Blind endometrial aspiration sampling is commonly used as a diagnostic procedure in the outpatient setting, but can cause severe discomfort and pain. Previous studies show that women highly value clear explanations and appropriate management of expectations during gynecological outpatient procedures. We believe that patients’ satisfaction is significantly influenced by these expectations, and thus, we consider counseling by gynecologists to play a crucial role in a patient’s comfort experience. The aim of this qualitative study is to explore counseling practices with a special focus on managing expectations regarding outpatient endometrial aspiration. Methods We conducted a qualitative study to explore communication by gynecologists (in training) with patients during an initial visit for postmenopausal bleeding. We interviewed experienced gynecologists (in training) from multiple medical centers. Grounded theory was used for methodological orientation. Results This qualitative study showed that, during the visit, gynecologists do inform patients about the procedure and its anticipated experience, but often reassure patients as a method to alleviate anxiety. Most respondents used alternative terminology to describe the procedure instead of directly mentioning ‘pain’. We also observed that the amount of information women receive prior to their visit (e.g. by the general practitioner or using a leaflet) is limited. Most respondents state that every aspect of the consultation should be detailed in an information leaflet, including information about potentially painful procedures, although some respondents believe this information could provoke anxiety. Conclusion Gynecologists do inform patients during their visit about the procedure. It is debatable whether gynecologist should specify the degree and nature of pain patients may potentially experience during a procedure or if we should use alternative terminology to describe the procedure while acknowledging the discomfort without explicitly detailing the extent and nature of pain. At this moment little information is provided prior to the visit. Most respondents supported the idea of a standard information leaflet, sent prior to the procedure, as it may potentially be a helpful tool to reduce anxiety and therefore dissatisfaction. Postmenopausal bleeding endometrial sampling patient preferences patient satisfaction anxiety Background Postmenopausal vaginal bleeding is a common complaint and requires diagnostic work-up to rule out endometrial cancer and other endometrial or cervical pathologies. Blind endometrial aspiration sampling (hereafter referred to as endometrial aspiration) is a commonly used diagnostic procedure in the outpatient setting with a high diagnostic accuracy to detect endometrial cancer. 1 Unfortunately, endometrial aspiration can cause severe discomfort and pain during and after the procedure, resulting in patients’ dissatisfaction. Previous research on endometrial aspiration showed pain scores (on a scale of 0–10) of 5.1 to 6. Forty-two% of women reported that the procedure was ‘worse than expected’ while 27% experienced the sampling as ‘very or extremely unpleasant’. 2 – 4 These experiences of pain and discomfort are challenging for health care providers, as patients might be discouraged to visit the outpatient clinic to undergo the procedure while outpatient endometrial aspiration is an accurate, fast and cost-efficient procedure. 5 It is known that patient satisfaction in healthcare is determined by the difference between expectation of a procedure and the experience of the actual procedure. 6 Previous research showed that women who have been counselled thoroughly on the aspects and duration of the procedure are able to manage pain during gynecological procedures in the most optimal way. 7 , 8 Furthermore, Vitale et al. stated that pre-procedural counselling should include appropriate counselling on anticipated pain or anxiety prior to the procedure to reduce anxiety levels. 9 A recent survey-report concluded that most women (97%) undergoing gynecological examination rate ‘explanations prior to and during examination’, ‘detailed warnings before painful procedures’ and ‘time for questions after examinations’ as (very) important. Moreover; ‘detailed warnings before painful procedures’ and ‘time for questions after examinations’ were associated with lower levels of physical pain and lower levels of traumatic experiences. 10 These previous studies show that women appreciate explanation and appropriate management of expectations during gynecological outpatient procedures. As we believe that patients’ satisfaction is considerably influenced by these expectations, we believe that the counseling by gynecologists plays a crucial role in the care for women who visit the outpatient clinic for postmenopausal bleeding. The aim of this study is to explore counseling practices in women with postmenopausal bleeding with a special focus on managing expectations regarding outpatient endometrial aspiration. Methods We conducted a qualitative study to explore communication and counseling strategies by gynecologists (in training) with patients during a first visit for postmenopausal bleeding. The semi-structured interview included multiple topics starting from the type of referral to the post-procedural work-up to make sure no essential parts in the patient communication would be missed. Grounded theory was used for methodological orientation. 11 We used the Consolidated criteria for Reporting Qualitative research (COREQ), a 32-item checklist to design our study. Being devoid of patient participation, the study was not covered by the Medical Research Involving Human Subjects Act (WMO), in accordance with the Declaration of Helsinki. Medical Research Ethics Committee’s approval was obtained (Máxima Medical Center, Veldhoven; registration number N22.079). We invited experienced gynecologists (in training) from multiple medical centers including (academic, larger teaching and smaller general hospitals) who routinely conduct consultations for women with postmenopausal bleeding. They were contacted by email to request participation. Contact details were collected from our (members only) digital platform of the Dutch Society of Obstetrics and Gynaecology (NVOG). The participants were informed about the aim of the study (‘to provide insight in counseling of women with postmenopausal bleeding’), but were not informed about the detailed findings of patient preferences known from literature, in order to prevent bias. Interviews were held by video conference with one of the authors (AV). An interview guide was developed to conduct semi-structured interviews to help retrieving essential data during the interviews. The interviewer was able to add open and in-depth questions during the interview to clarify the answers and therefore retrieve additional information about the counseling process. Throughout the iterative process, the interviewer employed constant comparison of data collection and analysis. 11 We continued data collection until data saturation, which meant that data did not provide new topics and themes during simultaneous analysis. Data analysis The interviews were recorded and transcribed. Information which could identify the participants was removed. The transcribed data was analyzed using MAXQDA (version 20.4.2). An inductive iterative technique by Straus&Corbin was used for analysis. Data was labelled into codes and categories simultaneously with data collection to enable constant comparison up until saturation occurred. Data was labelled again into codes and categories with a two week-interval to establish the intra-rater reliability. Memos were used to derive hypotheses. These hypotheses and memos were used to finally build a theory which could be used in further research. Results Data saturation occurred after 12 interviews. Interviews took between 15:53 and 38:00 minutes. We interviewed respondents working in 10 different hospitals spread over the east-, west-, and south regions of the Netherlands. Four of the 12 respondents were gynecologists in training, who all passed the first four years residency of ‘basic primary care for obstetrics and gynecology’. The following five categories were observed after inductive coding: pre-visit information, pre-procedural counseling, support and guidance during procedure, support and guidance in patients with anxiety and post procedural management. Pre-visit information The respondents were asked about the information patients usually receive prior to the visit. The majority of the respondents indicated that the general practitioner provides little information before referral, judged by the feedback they receive during the consultation. One respondent stated that they would question ‘whether the general practitioner would be trained sufficiently to counsel the patients with correct perspectives’ (R2). All except one respondent indicated that patients do not receive specific information about postmenopausal bleeding, or diagnostic procedures, prior to the visit. However, most respondents would like this information to be sent upfront beforehand the consultation. Information about postmenopausal bleeding is available online at the nationally supported website assigned to inform patients with gynecological conditions ‘degynaecoloog.nl’. The respondents are under the impression that patients are unaware of this platform. R3 "Of course, there's quite a lot on gynaecoloog.nl and similar resources. But it's not accessible to everyone just yet, in the sense that people simply can't find it." We asked all the respondents for their input om what they believe should be included in an informational leaflet. Most respondents indicated that patients should be informed about the symptoms, the reason for the consultation regarding the general probability of a malignancy, and some information about the possible procedures during the consultation. R4: "I might be missing a piece of counseling before the visit. That people receive more information about the examination we are going to conduct and the reason they are being put on the emergency list. And if you do so, perhaps provide some information about the follow-up, the subsequent appointments, the pathologist examining it, and a preliminary discussion about potential causes as well." A few respondents indicated they would send some information but they prefer for this information to be limited as they would be afraid to ‘overinform’ the patients, which could lead to anxiety. R3 "There are, of course, people who are always afraid of gynecological examinations. But I don't believe that providing more information would make them even more afraid." Pre-procedural counselling The respondents were asked about the counseling during the visit. This includes the counseling about the causes of the bleeding, explanations about risk factors and counseling about the procedures during the visit. The majority of respondents indicated that they believe it is important to explain which conditions could cause the bleeding and inform the patients that it is important to exclude a malignancy. In most cases the respondents would primarily reassure patients with postmenopausal bleeding on the a-priori risk of a malignancy, and most of the respondents take the age of the patient into consideration during this counseling. Some respondents take obesity into consideration during counseling, no other indicators were taken into consideration. R5: "And if there is a low chance of malignancy, I explain: it's purely for the sake of certainty that we're doing this, and then I can also quickly reassure you." Most respondents indicated that they would rather not inform patients about the possibility of failure of the procedures ‘because chances of failure are low (R6)’ and ‘because this is not very promising (R7)’ . The counseling about the endometrial aspiration procedure was quite similar for all respondents. They usually indicate that it is an ‘unpleasant’ procedure to ‘retrieve some tissue of the inner lining of the uterus’ . Almost all respondents indicated that it is a ‘brief procedure’. During analysis, we interpreted that this statement would be mentioned with the aim to comfort the patient. Also, almost all respondents indicated that they would ensure the patient feels in control during the procedure and would stop the procedure if requested by the patient at any time. This method was especially used for patients experiencing anxiety. R3(about what they explain about the endometrial aspiration procedure): "That I've never experienced it myself. That it's quite an uncomfortable examination. That, at least, many women do find it uncomfortable and painful. Because it can indeed cause some cramps. That it's brief in duration. That if it's too uncomfortable for them, they should let me know and I will stop." R2: "I believe that the way you phrase it is important. So, I think it's good to describe what an endometrial aspiration entails, and that it's also a brief procedure." Most respondents do not use the word ‘pain’ but use words like: ‘unpleasant’ or ‘annoying’ or they describe ‘ cramping’. One of the respondents indicated that they recently updated their counseling following new insights. They believe using the word ‘pain’ could cause more discomfort during the procedure so they now use words like: ‘you may feel this’ and avoid the word pain. R1: "I recently attended a presentation by a colleague who talked about pain. He mentioned: you actually shouldn't say that something is going to be painful, because if you tell them they're going to feel pain, they'll feel it more. […]. I'm trying something like: you might feel a sensation. On one hand, I believe I need to be honest: if something is going to be painful, they need to know, or they won't trust me if it does become painful. But on the other hand, I do think he was right with what he said in the presentation, so I'm trying to avoid using the phrase 'it's going to be painful.' [...]I do have the impression that now, when I don't explicitly say it's going to be painful but instead say: you'll feel it but it's manageable, that approach works better." When patients specifically ask whether the procedure is painful, all respondents indicate that they believe being honest is more important and therefore tell patients it could be painful. R8: "Yes, I usually don't use the word 'pain,' but rather 'uncomfortable.' It's just that people tend to get so tense if you mention pain. And when people ask whether it will hurt, I respond with 'well, it does cause some pain,' I'm not lying." Support and guidance during procedure All respondents indicated that they are constantly focused on the patient’s wellbeing during the endometrial aspiration procedure. By checking whether the patient is comfortable to proceed, the respondents indicated they were able to ensure the patient remained in control throughout the entire procedure. R8: "I always observe, and I also teach my medical students to observe facial expressions. And I ask: is this okay for you? I always let them be in control. If you say stop, then I'll stop." This seems like an important ‘tool’ for respondents to support and guide their patients during the endometrial aspiration. A second ‘tool’ which was indicated by many respondents was to ensure the patient would be distracted during the procedure. Most respondents indicated that they believe it is important to inform patients about the progress of the procedure and give a specific warning before the endometrial aspiration. R9: "I feel that if you say nothing, they might get quite startled, and I don't think that helps them. But I do change directly to light conversation afterwards." Support and guidance in patient experiencing anxiety All respondents indicated that they adjust the counseling in anxious patients. Respondents have the impression that patients showing anxiety for the diagnoses usually also show anxiety for the whole consultation and therefore, for a painful procedure. R10: "People who are anxious about the diagnosis often remain tense during the examination, in my experience. They tend to be more anxious overall." Most respondents specifically ask women about prior negative or traumatic experiences to adjust their counseling in these patients. All respondents indicated they ensure the anxious patient to stay in control during the whole procedure. They ensure that the patient could stop the procedure at any time. Often, an alternative method, e.g. a procedure with procedural sedation, is offered before the procedure in case it is anticipated to be unsuccessful in the outpatient setting. Almost all respondents indicated they would take more time for coaching in case patients experience anxiety. Furthermore, several respondents indicated they had extra support of a nurse or assistant available who could support the patient throughout the procedure. R7 : " Personally, I find it most rewarding in my profession that we have to adapt to the patient in front of me during a consultation. It's an integral part of the medical history-taking: considering who is in front of me and how best to listen to her or take her situation into account. For instance, if there's a patient who has had multiple pregnancies and has no issues with gynecological examinations, the process tends to go smoother than someone who has negative sexual experiences, is a virgin, or has a complex medical history. In those cases, I intentionally allocate more time, attention, and a calm environment." R11 (about a recent patient contact): "I mentioned that we have time, no rush, and that we proceed at a pace that's comfortable. You are in charge, if you say stop, I'll stop. That patient also mentioned that she found the consultation very reassuring. You can really see that patients are able to relax a bit more, even if just for a moment, and feel a sense of relief." R6 "Attention is crucial; the procedure itself doesn't really amount to much, of course." Post procedural management We asked all the respondents about the counseling after the procedures. Most respondents indicated that patients ask remarkably few questions afterwards. They presume patients are mainly focused on the pathological report and when and how they will receive it. When we asked the respondents about postprocedural symptoms they informed the patients of, the majority mentioned some blood loss ‘for a couple of days’ or ‘for 1 or 2 weeks’. The majority also indicated the ‘cramping’ or ‘annoying’ feeling could linger on but without specifying the duration. Some respondents recommend patients to take a painkiller afterwards. R7: "I often find it notable that they don't inquire about potential post-examination symptoms. They hardly ever ask about that. I do mention it quite often, saying 'you might have some discharge in the next few days,' especially if I observe some bleeding after collecting the smear. I always point out that they can take a sanitary pad when they get dressed again. The question rarely arises from patients themselves. They're focused on the results and what happens next." Reflecting upon patients enquiring about preliminary diagnoses, the results varied; some respondents do make a preliminary statement but others are reluctant, sometimes based on a previous misdiagnosis. R1: "I've been influenced by a case my colleague had: she saw a very irregular polyp in an elderly lady, and after the hysteroscopy and removal, she was honest about her concern. Ultimately, it turned out to be benign, but the woman filed a complaint because she was needlessly worried. So, I tend to keep it more ambiguous now: ‘I wish I knew for sure, but the pathologist has the final say." Most respondents are aware of the fact that 40–80% of the information provided by healthcare practitioners is forgotten immediately. 12 The respondents indicated that they believe it might be helpful to send an informational leaflet prior to the visit to help patients understand and recall the information they will receive during the consultation. R12: "I do believe that we are aware that only 20% of what we tell patients actually sticks. The way doctors deliver information, I think that's crucial. Patients become worried if the doctor appears worried." R1: "Yes, that's why I would like to provide information beforehand. So that they can already know what to expect, read about it in advance. This way, they can recognize what happens during the examination. They could also read it afterward, if needed." Discussion This qualitative study analyzed the counseling strategies used by gynecologists (in training) for women presenting with postmenopausal bleeding using an iterative process of data collection and analysis. Within this analysis we especially focused on the counseling of the endometrial aspiration as we wanted to explore the management of expectations for this painful procedure. We conclude that, during the visit, gynecologists do inform patients about the procedure and what to expect, but tend to reassure patients as a method to alleviate anxiety. We also observed that the amount of information women receive prior to the visit is low. Most respondents state that every aspect of the consult should be explained in an informational leaflet, also about the painful procedures, but some respondents believe this information could cause anxiety. No literature exists on information provision prior to a consultation for postmenopausal bleeding. However, this specific question was studied by Pollard et al. in patients undergoing a breast biopsy. 13 In their study, patients considered it really helpful to receive detailed information about the biopsy prior to their visit, both for patients who had to undergo the biopsy and those who did not. [16] This study indicates that a detailed informational leaflet may be helpful. Respondents contemplated on the lack of questions after the procedure. It is possible that women are overwhelmed by the amount of information they receive during the consultation. Furthermore, it is widely recognized that 40–80% of the information provided by healthcare practitioners is forgotten immediately. 12 Sending information prior to the consultation may enable women to better process the information provided during the consultation. The respondents believe it is important that the patient is well-prepared and the majority of respondents explained that the endometrial aspiration could cause discomfort. However, most respondents used different terminology, other than ‘pain’, to describe the procedure. It is debatable whether we should specify the degree and nature of pain patients may experience, or if we should use alternative terminology to explain the procedure and admit they may feel the procedure without specifying the degree and nature of pain. This last method, is described in literature by Lang et al. as ‘comfort talk’. 14 One of the respondents specifically indicated that they recently updated the counseling strategy to the use of comfort talk and had experienced positive results after this change (R1). It is possible that respondents are aware of previous literature that ‘words can hurt’ and therefore prefer not to use the word ‘pain’. 15 Comfort talk on the other hand comprehends more than just avoiding specific words, as it is about correct use of suggestions and usage of scripted language. When considering methods to comfort patients who have to undergo an endometrial aspiration, this could be an interesting method to explore for further research. The strength of this study is its qualitative character and the use of constant comparison during the iterative process of data collection and analysis. With this constant comparison the interviewer was able to explore the counseling strategies in greater depth and to anticipate on emerging subjects during the interviews. Furthermore, a wide range of gynecologists participated in the study, both gynecologists in training and more experienced gynecologists from either academic and larger teaching hospitals and smaller general hospitals. A limitation could be that the analysis was done by one member of the research team, which could have an impact on the interpretation and therefore the analysis. Another limitation is the fact that this study was only executed in the Netherlands, which could impact the reportability as the diagnostic work-up in women presenting with postmenopausal bleeding is different in other countries. 16 – 18 Conclusion This qualitative study analyzed the counseling practices used by gynecologists, regarding counseling of endometrial aspiration, as we wanted to explore the management of expectations for this probably painful procedure. We conclude that gynecologists do inform patients during their visit about the procedure but tend to reassure patients to alleviate anxiety. It is debatable which specific terminology should be used to specify the degree and nature of pain patients may experience, as some believe that the word ‘pain’ might induce more pain during the procedure. Conversely, gynecologist also want to be reliable and want women to be well-prepared. At this moment little information is provided prior to the visit and it is unclear whether patients should receive detailed information on every aspect prior to the visit. However, many respondents supported the idea of a standard information leaflet, sent prior to the procedure, as it might be a helpful tool to reduce anxiety and therefore dissatisfaction This paper could be used as a foundation to conduct research and set up a complete guide for the research on patient satisfaction in women with postmenopausal bleeding. As a next step, a qualitative study using focus groups in women with postmenopausal bleeding could be conducted to evaluate patient satisfaction with the counseling practices and to evaluate the findings derived from this paper. Declarations Ethics approval consent to participate : Being devoid of patient participation, the study was not covered by the Medical Research Involving Human Subjects Act (WMO) in accordance with the Declaration of Helsinki. Medical Research Ethics Committee’s approval was obtained (Máxima Medical Center, Veldhoven; registration number N22.079). Written informed consent was retrieved form the gynecologists (in training) who participated in the study. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interest: The authors declare that they have no competing interests Funding: This research received no funding Author contributions: AV: Conceptualization, Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation; NvH: Conceptualization, Writing – Review & Editing; HW: Writing – Review & Editing; MB: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Review & Editing; PG: Conceptualization, Formal Analysis, Methodology, Writing – Review & Editing Acknowledgements: Not applicable References van Hanegem N, Prins MMC, Bongers MY, et al. The accuracy of endometrial sampling in women with postmenopausal bleeding: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2016;197:147–55. Van den Bosch T, Verguts J, Daemen A, et al. Pain experienced during transvaginal ultrasound, saline contrast sonohysterography, hysteroscopy and office sampling: a comparative study. Ultrasound Obstet Gynecol. 2008;31(3):346–51. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4873136","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":342482299,"identity":"eff69b8e-4478-449b-8b42-6d002755b459","order_by":0,"name":"Albertine J Vroom","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYFCCA2BSDsx8QIoWYzAzgRS7EhtAJFFa+BvPmH34ULEtfX7Y4YdAW+zkdBsIaJE4cMZ45owzt3M33k4zAGpJNjY7QMiaA8eSmXnbgFpmJ4C0HEjcRkiLPFRLuuHs9A/EaTE4cPgwSEuCvHQOkbYYArUwAv1iuEE6p+BAggERfpG7cbCZ4UPFbXn52embgUFnJ0fY+xIHYC4Ek4SUgwB/A4SWbyBG9SgYBaNgFIxIAAAmMkwZVEY7BwAAAABJRU5ErkJggg==","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Albertine","middleName":"J","lastName":"Vroom","suffix":""},{"id":342482300,"identity":"4a3ff061-d9fe-425e-9a71-f68c977a99c4","order_by":1,"name":"Nehalennia van Hanegem","email":"","orcid":"","institution":"University Medical Center Utrecht","correspondingAuthor":false,"prefix":"","firstName":"Nehalennia","middleName":"van","lastName":"Hanegem","suffix":""},{"id":342482301,"identity":"917f631e-3dba-4c9a-9030-2041b62187aa","order_by":2,"name":"Henrica MJ Werner","email":"","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Henrica","middleName":"MJ","lastName":"Werner","suffix":""},{"id":342482302,"identity":"0a0fece5-b59d-47dc-9043-0432de3febef","order_by":3,"name":"Marlies Y Bongers","email":"","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Marlies","middleName":"Y","lastName":"Bongers","suffix":""},{"id":342482303,"identity":"86989d81-fc75-47c7-9500-7f801660c989","order_by":4,"name":"Peggy MAJ Geomini","email":"","orcid":"","institution":"Máxima Medisch Centrum","correspondingAuthor":false,"prefix":"","firstName":"Peggy","middleName":"MAJ","lastName":"Geomini","suffix":""}],"badges":[],"createdAt":"2024-08-07 08:32:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4873136/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4873136/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64486286,"identity":"32037159-f078-4949-a0bc-1fca2e0563b2","added_by":"auto","created_at":"2024-09-13 17:58:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":397375,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4873136/v1/b11faea4-3656-4828-8fc6-b620c23f35c8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outpatient visits for women with postmenopausal bleeding; What do we tell our patients? A Qualitative study","fulltext":[{"header":"Background","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003ePostmenopausal vaginal bleeding is a common complaint and requires diagnostic work-up to rule out\u003c/h2\u003e \u003cp\u003eendometrial cancer and other endometrial or cervical pathologies. Blind endometrial aspiration sampling (hereafter referred to as endometrial aspiration) is a commonly used diagnostic procedure in the outpatient setting with a high diagnostic accuracy to detect endometrial cancer.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Unfortunately, endometrial aspiration can cause severe discomfort and pain during and after the procedure, resulting in patients\u0026rsquo; dissatisfaction. Previous research on endometrial aspiration showed pain scores (on a scale of 0\u0026ndash;10) of 5.1 to 6. Forty-two% of women reported that the procedure was \u0026lsquo;worse than expected\u0026rsquo; while 27% experienced the sampling as \u0026lsquo;very or extremely unpleasant\u0026rsquo;.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e These experiences of pain and discomfort are challenging for health care providers, as patients might be discouraged to visit the outpatient clinic to undergo the procedure while outpatient endometrial aspiration is an accurate, fast and cost-efficient procedure.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIt is known that patient satisfaction in healthcare is determined by the difference between expectation\u003c/h2\u003e \u003cp\u003eof a procedure and the experience of the actual procedure.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Previous research showed that women who have been counselled thoroughly on the aspects and duration of the procedure are able to manage pain during gynecological procedures in the most optimal way.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Furthermore, Vitale et al. stated that pre-procedural counselling should include appropriate counselling on anticipated pain or anxiety prior to the procedure to reduce anxiety levels.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e A recent survey-report concluded that most women (97%) undergoing gynecological examination rate \u0026lsquo;explanations prior to and during examination\u0026rsquo;, \u0026lsquo;detailed warnings before painful procedures\u0026rsquo; and \u0026lsquo;time for questions after examinations\u0026rsquo; as (very) important. Moreover; \u0026lsquo;detailed warnings before painful procedures\u0026rsquo; and \u0026lsquo;time for questions after examinations\u0026rsquo; were associated with lower levels of physical pain and lower levels of traumatic experiences.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThese previous studies show that women appreciate explanation and appropriate management of expectations during gynecological outpatient procedures. As we believe that patients\u0026rsquo; satisfaction is considerably influenced by these expectations, we believe that the counseling by gynecologists plays a crucial role in the care for women who visit the outpatient clinic for postmenopausal bleeding.\u003c/p\u003e \u003cp\u003eThe aim of this study is to explore counseling practices in women with postmenopausal bleeding with a special focus on managing expectations regarding outpatient endometrial aspiration.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a qualitative study to explore communication and counseling strategies by gynecologists (in training) with patients during a first visit for postmenopausal bleeding. The semi-structured interview included multiple topics starting from the type of referral to the post-procedural work-up to make sure no essential parts in the patient communication would be missed. Grounded theory was used for methodological orientation.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e We used the Consolidated criteria for Reporting Qualitative research (COREQ), a 32-item checklist to design our study.\u003c/p\u003e \u003cp\u003e Being devoid of patient participation, the study was not covered by the Medical Research Involving Human Subjects Act (WMO), in accordance with the Declaration of Helsinki. Medical Research Ethics Committee\u0026rsquo;s approval was obtained (M\u0026aacute;xima Medical Center, Veldhoven; registration number N22.079).\u003c/p\u003e \u003cp\u003eWe invited experienced gynecologists (in training) from multiple medical centers including (academic, larger teaching and smaller general hospitals) who routinely conduct consultations for women with postmenopausal bleeding. They were contacted by email to request participation. Contact details were collected from our (members only) digital platform of the Dutch Society of Obstetrics and Gynaecology (NVOG). The participants were informed about the aim of the study (\u0026lsquo;to provide insight in counseling of women with postmenopausal bleeding\u0026rsquo;), but were not informed about the detailed findings of patient preferences known from literature, in order to prevent bias. Interviews were held by video conference with one of the authors (AV).\u003c/p\u003e \u003cp\u003eAn interview guide was developed to conduct semi-structured interviews to help retrieving essential data during the interviews. The interviewer was able to add open and in-depth questions during the interview to clarify the answers and therefore retrieve additional information about the counseling process. Throughout the iterative process, the interviewer employed constant comparison of data collection and analysis. \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e We continued data collection until data saturation, which meant that data did not provide new topics and themes during simultaneous analysis.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe interviews were recorded and transcribed. Information which could identify the participants was removed. The transcribed data was analyzed using MAXQDA (version 20.4.2). An inductive iterative technique by Straus\u0026amp;Corbin was used for analysis. Data was labelled into codes and categories simultaneously with data collection to enable constant comparison up until saturation occurred. Data was labelled again into codes and categories with a two week-interval to establish the intra-rater reliability. Memos were used to derive hypotheses. These hypotheses and memos were used to finally build a theory which could be used in further research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eData saturation occurred after 12 interviews. Interviews took between 15:53 and 38:00 minutes. We interviewed respondents working in 10 different hospitals spread over the east-, west-, and south regions of the Netherlands. Four of the 12 respondents were gynecologists in training, who all passed the first four years residency of \u0026lsquo;basic primary care for obstetrics and gynecology\u0026rsquo;. The following five categories were observed after inductive coding: pre-visit information, pre-procedural counseling, support and guidance during procedure, support and guidance in patients with anxiety and post procedural management.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePre-visit information\u003c/h2\u003e \u003cp\u003eThe respondents were asked about the information patients usually receive prior to the visit. The majority of the respondents indicated that the general practitioner provides little information before referral, judged by the feedback they receive during the consultation. One respondent stated that they would question \u0026lsquo;whether the general practitioner would be trained sufficiently to counsel the patients with correct perspectives\u0026rsquo; (R2).\u003c/p\u003e \u003cp\u003eAll except one respondent indicated that patients do not receive specific information about postmenopausal bleeding, or diagnostic procedures, prior to the visit. However, most respondents would like this information to be sent upfront beforehand the consultation. Information about postmenopausal bleeding is available online at the nationally supported website assigned to inform patients with gynecological conditions \u0026lsquo;degynaecoloog.nl\u0026rsquo;. The respondents are under the impression that patients are unaware of this platform.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eR3\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\"Of course, there's quite a lot on gynaecoloog.nl and similar resources. But it's not accessible to everyone just yet, in the sense that people simply can't find it.\"\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe asked all the respondents for their input om what they believe should be included in an informational leaflet. Most respondents indicated that patients should be informed about the symptoms, the reason for the consultation regarding the general probability of a malignancy, and some information about the possible procedures during the consultation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR4: \"I might be missing a piece of counseling before the visit. That people receive more information about the examination we are going to conduct and the reason they are being put on the emergency list. And if you do so, perhaps provide some information about the follow-up, the subsequent appointments, the pathologist examining it, and a preliminary discussion about potential causes as well.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA few respondents indicated they would send some information but they prefer for this information to be limited as they would be afraid to \u0026lsquo;overinform\u0026rsquo; the patients, which could lead to anxiety.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eR3\u003c/strong\u003e \u003cp\u003e \u003cem\u003e\"There are, of course, people who are always afraid of gynecological examinations. But I don't believe that providing more information would make them even more afraid.\"\u003c/em\u003e \u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePre-procedural counselling\u003c/h2\u003e \u003cp\u003eThe respondents were asked about the counseling during the visit. This includes the counseling about the causes of the bleeding, explanations about risk factors and counseling about the procedures during the visit. The majority of respondents indicated that they believe it is important to explain which conditions could cause the bleeding and inform the patients that it is important to exclude a malignancy. In most cases the respondents would primarily reassure patients with postmenopausal bleeding on the a-priori risk of a malignancy, and most of the respondents take the age of the patient into consideration during this counseling. Some respondents take obesity into consideration during counseling, no other indicators were taken into consideration.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR5: \"And if there is a low chance of malignancy, I explain: it's purely for the sake of certainty that we're doing this, and then I can also quickly reassure you.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMost respondents indicated that they would rather not inform patients about the possibility of failure of the procedures \u003cem\u003e\u0026lsquo;because chances of failure are low (R6)\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;because this is not very promising (R7)\u0026rsquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe counseling about the endometrial aspiration procedure was quite similar for all respondents. They usually indicate that it is an \u003cem\u003e\u0026lsquo;unpleasant\u0026rsquo;\u003c/em\u003e procedure to \u003cem\u003e\u0026lsquo;retrieve some tissue of the inner lining of the uterus\u0026rsquo;\u003c/em\u003e. Almost all respondents indicated that it is a \u0026lsquo;brief procedure\u0026rsquo;. During analysis, we interpreted that this statement would be mentioned with the aim to comfort the patient. Also, almost all respondents indicated that they would ensure the patient feels in control during the procedure and would stop the procedure if requested by the patient at any time. This method was especially used for patients experiencing anxiety.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR3(about what they explain about the\u003c/em\u003e endometrial aspiration \u003cem\u003eprocedure): \"That I've never experienced it myself. That it's quite an uncomfortable examination. That, at least, many women do find it uncomfortable and painful. Because it can indeed cause some cramps. That it's brief in duration. That if it's too uncomfortable for them, they should let me know and I will stop.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eR2: \"I believe that the way you phrase it is important. So, I think it's good to describe what an\u003c/em\u003e endometrial aspiration \u003cem\u003eentails, and that it's also a brief procedure.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMost respondents do not use the word \u0026lsquo;pain\u0026rsquo; but use words like: \u003cem\u003e\u0026lsquo;unpleasant\u0026rsquo;\u003c/em\u003e or \u003cem\u003e\u0026lsquo;annoying\u0026rsquo;\u003c/em\u003e or they describe \u003cem\u003e\u0026lsquo;\u003c/em\u003ecramping\u0026rsquo;. One of the respondents indicated that they recently updated their counseling following new insights. They believe using the word \u0026lsquo;pain\u0026rsquo; could cause more discomfort during the procedure so they now use words like: \u0026lsquo;you may feel this\u0026rsquo; and avoid the word pain.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR1: \"I recently attended a presentation by a colleague who talked about pain. He mentioned: you actually shouldn't say that something is going to be painful, because if you tell them they're going to feel pain, they'll feel it more. [\u0026hellip;]. I'm trying something like: you might feel a sensation. On one hand, I believe I need to be honest: if something is going to be painful, they need to know, or they won't trust me if it does become painful. But on the other hand, I do think he was right with what he said in the presentation, so I'm trying to avoid using the phrase 'it's going to be painful.' [...]I do have the impression that now, when I don't explicitly say it's going to be painful but instead say: you'll feel it but it's manageable, that approach works better.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWhen patients specifically ask whether the procedure is painful, all respondents indicate that they believe being honest is more important and therefore tell patients it could be painful.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR8: \"Yes, I usually don't use the word 'pain,' but rather 'uncomfortable.' It's just that people tend to get so tense if you mention pain. And when people ask whether it will hurt, I respond with 'well, it does cause some pain,' I'm not lying.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSupport and guidance during procedure\u003c/h2\u003e \u003cp\u003eAll respondents indicated that they are constantly focused on the patient\u0026rsquo;s wellbeing during the endometrial aspiration procedure. By checking whether the patient is comfortable to proceed, the respondents indicated they were able to ensure the patient remained in control throughout the entire procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR8: \"I always observe, and I also teach my medical students to observe facial expressions. And I ask: is this okay for you? I always let them be in control. If you say stop, then I'll stop.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis seems like an important \u0026lsquo;tool\u0026rsquo; for respondents to support and guide their patients during the endometrial aspiration. A second \u0026lsquo;tool\u0026rsquo; which was indicated by many respondents was to ensure the patient would be distracted during the procedure. Most respondents indicated that they believe it is important to inform patients about the progress of the procedure and give a specific warning before the endometrial aspiration.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR9: \"I feel that if you say nothing, they might get quite startled, and I don't think that helps them. But I do change directly to light conversation afterwards.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSupport and guidance in patient experiencing anxiety\u003c/h2\u003e \u003cp\u003eAll respondents indicated that they adjust the counseling in anxious patients. Respondents have the impression that patients showing anxiety for the diagnoses usually also show anxiety for the whole consultation and therefore, for a painful procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR10: \"People who are anxious about the diagnosis often remain tense during the examination, in my experience. They tend to be more anxious overall.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMost respondents specifically ask women about prior negative or traumatic experiences to adjust their counseling in these patients.\u003c/p\u003e \u003cp\u003eAll respondents indicated they ensure the anxious patient to stay in control during the whole procedure. They ensure that the patient could stop the procedure at any time. Often, an alternative method, e.g. a procedure with procedural sedation, is offered before the procedure in case it is anticipated to be unsuccessful in the outpatient setting.\u003c/p\u003e \u003cp\u003eAlmost all respondents indicated they would take more time for coaching in case patients experience anxiety. Furthermore, several respondents indicated they had extra support of a nurse or assistant available who could support the patient throughout the procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR7\u003c/em\u003e: \"\u003cem\u003ePersonally, I find it most rewarding in my profession that we have to adapt to the patient in front of me during a consultation. It's an integral part of the medical history-taking: considering who is in front of me and how best to listen to her or take her situation into account. For instance, if there's a patient who has had multiple pregnancies and has no issues with gynecological examinations, the process tends to go smoother than someone who has negative sexual experiences, is a virgin, or has a complex medical history. In those cases, I intentionally allocate more time, attention, and a calm environment.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eR11 (about a recent patient contact): \"I mentioned that we have time, no rush, and that we proceed at a pace that's comfortable. You are in charge, if you say stop, I'll stop. That patient also mentioned that she found the consultation very reassuring. You can really see that patients are able to relax a bit more, even if just for a moment, and feel a sense of relief.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eR6 \"Attention is crucial; the procedure itself doesn't really amount to much, of course.\"\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePost procedural management\u003c/h2\u003e \u003cp\u003eWe asked all the respondents about the counseling after the procedures.\u003c/p\u003e \u003cp\u003eMost respondents indicated that patients ask remarkably few questions afterwards. They presume patients are mainly focused on the pathological report and when and how they will receive it.\u003c/p\u003e \u003cp\u003eWhen we asked the respondents about postprocedural symptoms they informed the patients of, the majority mentioned some blood loss \u0026lsquo;for a couple of days\u0026rsquo; or \u0026lsquo;for 1 or 2 weeks\u0026rsquo;. The majority also indicated the \u0026lsquo;cramping\u0026rsquo; or \u0026lsquo;annoying\u0026rsquo; feeling could linger on but without specifying the duration. Some respondents recommend patients to take a painkiller afterwards.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR7: \"I often find it notable that they don't inquire about potential post-examination symptoms. They hardly ever ask about that. I do mention it quite often, saying 'you might have some discharge in the next few days,' especially if I observe some bleeding after collecting the smear. I always point out that they can take a sanitary pad when they get dressed again. The question rarely arises from patients themselves. They're focused on the results and what happens next.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eReflecting upon patients enquiring about preliminary diagnoses, the results varied; some respondents do make a preliminary statement but others are reluctant, sometimes based on a previous misdiagnosis.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR1: \"I've been influenced by a case my colleague had: she saw a very irregular polyp in an elderly lady, and after the hysteroscopy and removal, she was honest about her concern. Ultimately, it turned out to be benign, but the woman filed a complaint because she was needlessly worried. So, I tend to keep it more ambiguous now: \u0026lsquo;I wish I knew for sure, but the pathologist has the final say.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMost respondents are aware of the fact that 40\u0026ndash;80% of the information provided by healthcare practitioners is forgotten immediately.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The respondents indicated that they believe it might be helpful to send an informational leaflet prior to the visit to help patients understand and recall the information they will receive during the consultation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eR12: \"I do believe that we are aware that only 20% of what we tell patients actually sticks. The way doctors deliver information, I think that's crucial. Patients become worried if the doctor appears worried.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eR1: \"Yes, that's why I would like to provide information beforehand. So that they can already know what to expect, read about it in advance. This way, they can recognize what happens during the examination. They could also read it afterward, if needed.\"\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study analyzed the counseling strategies used by gynecologists (in training) for women presenting with postmenopausal bleeding using an iterative process of data collection and analysis. Within this analysis we especially focused on the counseling of the endometrial aspiration as we wanted to explore the management of expectations for this painful procedure. We conclude that, during the visit, gynecologists do inform patients about the procedure and what to expect, but tend to reassure patients as a method to alleviate anxiety.\u003c/p\u003e \u003cp\u003eWe also observed that the amount of information women receive prior to the visit is low. Most respondents state that every aspect of the consult should be explained in an informational leaflet, also about the painful procedures, but some respondents believe this information could cause anxiety. No literature exists on information provision prior to a consultation for postmenopausal bleeding. However, this specific question was studied by Pollard et al. in patients undergoing a breast biopsy.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In their study, patients considered it really helpful to receive detailed information about the biopsy prior to their visit, both for patients who had to undergo the biopsy and those who did not. [16] This study indicates that a detailed informational leaflet may be helpful.\u003c/p\u003e \u003cp\u003eRespondents contemplated on the lack of questions after the procedure. It is possible that women are overwhelmed by the amount of information they receive during the consultation. Furthermore, it is widely recognized that 40\u0026ndash;80% of the information provided by healthcare practitioners is forgotten immediately.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Sending information prior to the consultation may enable women to better process the information provided during the consultation.\u003c/p\u003e \u003cp\u003eThe respondents believe it is important that the patient is well-prepared and the majority of respondents explained that the endometrial aspiration could cause discomfort. However, most respondents used different terminology, other than \u0026lsquo;pain\u0026rsquo;, to describe the procedure. It is debatable whether we should specify the degree and nature of pain patients may experience, or if we should use alternative terminology to explain the procedure and admit they may feel the procedure without specifying the degree and nature of pain. This last method, is described in literature by Lang et al. as \u0026lsquo;comfort talk\u0026rsquo;.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e One of the respondents specifically indicated that they recently updated the counseling strategy to the use of comfort talk and had experienced positive results after this change (R1). It is possible that respondents are aware of previous literature that \u0026lsquo;words can hurt\u0026rsquo; and therefore prefer not to use the word \u0026lsquo;pain\u0026rsquo;.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Comfort talk on the other hand comprehends more than just avoiding specific words, as it is about correct use of suggestions and usage of scripted language. When considering methods to comfort patients who have to undergo an endometrial aspiration, this could be an interesting method to explore for further research.\u003c/p\u003e \u003cp\u003eThe strength of this study is its qualitative character and the use of constant comparison during the iterative process of data collection and analysis. With this constant comparison the interviewer was able to explore the counseling strategies in greater depth and to anticipate on emerging subjects during the interviews. Furthermore, a wide range of gynecologists participated in the study, both gynecologists in training and more experienced gynecologists from either academic and larger teaching hospitals and smaller general hospitals. A limitation could be that the analysis was done by one member of the research team, which could have an impact on the interpretation and therefore the analysis. Another limitation is the fact that this study was only executed in the Netherlands, which could impact the reportability as the diagnostic work-up in women presenting with postmenopausal bleeding is different in other countries.\u003csup\u003e\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative study analyzed the counseling practices used by gynecologists, regarding counseling of endometrial aspiration, as we wanted to explore the management of expectations for this probably painful procedure. We conclude that gynecologists do inform patients during their visit about the procedure but tend to reassure patients to alleviate anxiety. It is debatable which specific terminology should be used to specify the degree and nature of pain patients may experience, as some believe that the word \u0026lsquo;pain\u0026rsquo; might induce more pain during the procedure. Conversely, gynecologist also want to be reliable and want women to be well-prepared. At this moment little information is provided prior to the visit and it is unclear whether patients should receive detailed information on every aspect prior to the visit. However, many respondents supported the idea of a standard information leaflet, sent prior to the procedure, as it might be a helpful tool to reduce anxiety and therefore dissatisfaction\u003c/p\u003e \u003cp\u003eThis paper could be used as a foundation to conduct research and set up a complete guide for the research on patient satisfaction in women with postmenopausal bleeding. As a next step, a qualitative study using focus groups in women with postmenopausal bleeding could be conducted to evaluate patient satisfaction with the counseling practices and to evaluate the findings derived from this paper.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval\u0026nbsp;\u003c/em\u003e\u003cem\u003econsent to participate\u003c/em\u003e\u003cem\u003e:\u003c/em\u003e Being devoid of patient participation, the study was not covered by the Medical Research Involving Human Subjects Act (WMO)\u0026nbsp;in accordance with the Declaration of Helsinki.\u0026nbsp;Medical Research Ethics Committee’s approval was obtained (Máxima Medical Center, Veldhoven; registration number N22.079). \u0026nbsp;Written informed consent was retrieved form the gynecologists (in training) who participated in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interest:\u003c/em\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u003c/em\u003e This research received no\u0026nbsp;funding\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor contributions:\u003c/em\u003e AV: Conceptualization, Data Curation, Formal Analysis, Investigation, Writing – Original Draft Preparation;\u0026nbsp;NvH: Conceptualization, Writing – Review \u0026amp; Editing;\u0026nbsp;HW: Writing – Review \u0026amp; Editing;\u0026nbsp;MB: Conceptualization, Formal Analysis, Methodology, Supervision, Writing – Review \u0026amp; Editing;\u0026nbsp;PG: Conceptualization, Formal Analysis, Methodology, Writing – Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003evan Hanegem N, Prins MMC, Bongers MY, et al. 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J Radiol Nurs [Internet]. 2012;31(4):114\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.jradnu.2012.08.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jradnu.2012.08.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRitter A, Franz M, Miltner WHR, Weiss T. How words impact on pain. Brain Behav [Internet]. 2019;9(9). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1002/brb3.1377\u003c/span\u003e\u003cspan address=\"10.1002/brb3.1377\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinical Pathway Postmenopausal Bleeding- UK, V21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinical-pathways.org.uk/sites/default/files/guidance/Gynaecology/management-post-menopausal-bleeding-v21.pdf\u003c/span\u003e\u003cspan address=\"https://clinical-pathways.org.uk/sites/default/files/guidance/Gynaecology/management-post-menopausal-bleeding-v21.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 12-2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunro M. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations [Internet]. Vol. 18, The Permanente journal. M.G. Munro; 2014. pp. 55\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://ovidsp.ovid.com/ovidweb.cgi?T=JS\u0026amp;PAGE=reference\u0026amp;D=emed12\u0026amp;NEWS=N\u0026amp;AN=24377427\u003c/span\u003e\u003cspan address=\"http://ovidsp.ovid.com/ovidweb.cgi?T=JS\u0026amp;PAGE=reference\u0026amp;D=emed12\u0026amp;NEWS=N\u0026amp;AN=24377427\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHG; NVOG. [LTA Vaginaal bloedverlies in de postmenopauze] (LTA Vaginal bloodloss in the postmenopause). 2019.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postmenopausal bleeding, endometrial sampling, patient preferences, patient satisfaction, anxiety","lastPublishedDoi":"10.21203/rs.3.rs-4873136/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4873136/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostmenopausal vaginal bleeding is a common complaint and requires diagnostic work-up to rule out endometrial cancer. Blind endometrial aspiration sampling is commonly used as a diagnostic procedure in the outpatient setting, but can cause severe discomfort and pain. Previous studies show that women highly value clear explanations and appropriate management of expectations during gynecological outpatient procedures. We believe that patients’ satisfaction is significantly influenced by these expectations, and thus, we consider counseling by gynecologists to play a crucial role in a patient’s comfort experience. The aim of this qualitative study is to explore counseling practices with a special focus on managing expectations regarding outpatient endometrial aspiration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a qualitative study to explore communication by gynecologists (in training) with patients during an initial visit for postmenopausal bleeding. We interviewed experienced gynecologists (in training) from multiple medical centers. Grounded theory was used for methodological orientation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis qualitative study showed that, during the visit, gynecologists do inform patients about the procedure and its anticipated experience, but often reassure patients as a method to alleviate anxiety. Most respondents used alternative terminology to describe the procedure instead of directly mentioning ‘pain’. We also observed that the amount of information women receive prior to their visit (e.g. by the general practitioner or using a leaflet) is limited. Most respondents state that every aspect of the consultation should be detailed in an information leaflet, including information about potentially painful procedures, although some respondents believe this information could provoke anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGynecologists do inform patients during their visit about the procedure. It is debatable whether gynecologist should specify the degree and nature of pain patients may potentially experience during a procedure or if we should use alternative terminology to describe the procedure while acknowledging the discomfort without explicitly detailing the extent and nature of pain. At this moment little information is provided prior to the visit. Most respondents supported the idea of a standard information leaflet, sent prior to the procedure, as it may potentially be a helpful tool to reduce anxiety and therefore dissatisfaction.\u003c/p\u003e","manuscriptTitle":"Outpatient visits for women with postmenopausal bleeding; What do we tell our patients? A Qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-13 17:34:22","doi":"10.21203/rs.3.rs-4873136/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-20T06:35:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-19T00:52:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-19T00:52:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2024-08-07T08:30:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ffb06bb3-0c45-4d82-a806-f6b692d4ffb1","owner":[],"postedDate":"September 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T06:57:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-13 17:34:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4873136","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4873136","identity":"rs-4873136","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}