Mirena®/progesterone releasing IUD Insertion or removal, for HMB or HRT
ADULT
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Ectopic pregnancy
- Ruptured haemorrhagic ovarian cyst
- Torsion of uterine appendages (ovarian)
- Acute/severe pelvic pain
- Significant or uncontrolled vaginal bleeding
- Severe infection
- Abscess intra pelvis or PID
- Bartholin's abscess / acute painful enlargement of a Bartholin's gland/cyst
- Acute trauma including vulva/vaginal lacerations, haematoma and/or penetrating injuries
- Post-operative complications within 6 weeks including wound infection, wound breakdown, vaginal bleeding/discharge, retained products of conception post-op, abdominal pain
- Urinary retention
- Acute urinary obstruction
- Unstable molar pregnancy
- Inevitable and / or incomplete abortion
- Hyperemesis gravidarum
- Ascites, secondary to known underlying gynaecological oncology
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| Category 1 (appointment within 30 calendar days) |
|
| Category 2 (appointment within 90 calendar days) |
|
| Category 3 (appointment within 365 calendar days) |
NB: Routine Mirena®/progesterone-releasing IUD insertion for contraception may be out-of-scope for certain Gynaecology services. |
Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
2. Essential referral information Referral will be returned without this
- Medical history -relevant family, menstrual, obstetric, contraceptive and brief sexual history or history of STDS
- Most recent or current cervical screening
- Mirena® prescription (The local service may require the referring GP to provide a prescription for the device to the patient who must bring the device with her to the clinic)
3. Additional referral information Useful for processing the referral
- BMI
- Pelvic USS if lost strings, HMB or other clinical indication
- STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA
4. Request
-
Patient's Demographic Details
- Full name (including aliases)
- Date of birth
- Residential and postal address
- Telephone contact number/s – home, mobile and alternative
- Medicare number (where eligible)
- Name of the parent or caregiver (if appropriate)
- Preferred language and interpreter requirements
- Identifies as Aboriginal and/or Torres Strait Islander
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- Presenting symptoms (evolution and duration)
- Physical findings
- Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
- Body mass index (BMI)
- Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
- Current medications and dosages
- Drug allergies
- Alcohol, tobacco and other drugs use
Reason for request
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
Clinical modifiers
- Impact on employment
- Impact on education
- Impact on home
- Impact on activities of daily living
- Impact on ability to care for others
- Impact on personal frailty or safety
- Identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery (where surgery is a likely intervention)
- Choice to be treated as a public or private patient
- Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
- Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
Last updated: 7 December 2020
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