Endometrial biopsies are performed to sample tissue from the endometrium to rule out suspected endometrial cancer in the setting of abnormal uterine bleeding. Although not a first-line investigation in a patient who presents with vaginal bleeding without risk factors for endometrial cancer, it is always a first-line investigation in a postmenopausal woman with abnormal uterine bleeding. The procedure can be done in the office, and often is done after transvaginal ultrasound to assess thickness and character of the endometrial lining. The only absolute contraindications are current pregnancy or a bleeding diathesis. Although I haven't yet seen one been doing ever in real-life yet, let alone having had the opportunity to try my hand at this procedure, we did have a clinical skills training day where we got to practice performing endometrial aspiration biopsies on kiwis... Apparently that's what it's like. I personally think doing it on a young coconut would be a better analogy, based on my understanding of what the texture of the endometrial lining must be like, but alas we don't live in Southeast Asia.
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Today in clinic I watched as my preceptor demonstrated how to insert an IUD. The patient was a 22 year-old nulliparous woman who was excited but nervous to have an IUD inserted. I reassured her that the pain of insertion would be better than the pain of having a baby. Haha. She tolerated the procedure well, and like most IUD patients, will probably go on to happily every after for at least 5 years (how long the Mirena, the most common form of the IUD, is guaranteed to last). The intrauterine device (IUD) is a wonderful little form of contraception. With an extremely high rate of success in staving off pregnancy (<1% chance of becoming pregnant), with a correspondingly low risk of failure (because once inserted, the patient doesn't need to do anything for it to work), it is a preferred method of contraception in any woman who is not contraindicated from having it. There are two types of IUDs, the original copper IUD and the levonorgestrel-containing IUD. The levonorgestrel-containing IUD is generally preferred because it contains locally-acting progesterone that prevents the endometrial lining from building up, which means that despite ongoing ovulation, a few months after insertion the woman generally no longer has menstrual periods (bonus!). However, it is contraindicated in women who have contraindications to using progesterone. The copper IUD can be used in women who have a contraindication to the hormone-containing option, although it tends to produce somewhat heavier periods than the woman normally has. Whenever the device is removed, the woman returns to having whatever menstrual cycles she would have without an IUD, and her fertility is back to what it would be for her natural history (this is why it is called a form of reversible contraception). Contraindications to receiving either form of IUD include:
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Illustrations demonstrating how to insert a Mirena (the most common levonorgestrel-containing IUD): Key Feature 4: Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (ex: positioning for Pap, chaperones for genital/rectal exams). Skill: Professionalism Phase: Physical Although many people think this test is synonymous with STI testing, it is completely not the same thing; the Papanicolaou (aka Pap) test examines purely for cervical cancer. Guidelines have been changing almost every other year it seems like. At the time of writing this blog, the Canadian national screening consensus is to begin Pap screening at the age of 25 (sooner if the patient has risk factors) and to screen every 3 years until the age of 69. There's no absolute contraindication to every doing this test per se, though the results may not be as accurate if there is current infection of the vaginitis, cervix, or pelvic inflammatory disease (so is in fact ideally NOT done when there is suspicion for an STI), or if the woman is menstruating. Not that if the bleeding is not a regular menstrual bleed but rather abnormal vaginal bleeding, obtaining a Pap would be important as a diagnostic as opposed to screening tool and would thus be indicated for that purpose. Equipment
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Bladder catheterization is a procedure that is done frequently in the emergency room, operating room, and in-patient hospital setting. It may be done for investigations such as monitoring urine output or to obtain a sample of urine for analysis, or it may be done as a therapeutic intervention to relieve urinary retention or to manage urine output while undergoing an operation. Depending on the reason, it may be done as an in-and-out catheter, or may remain in-situ for some amount of time, which comes with increased risk of infection, which could evolve into urosepsis, and so is avoided when possible. It is contraindicated if there is suspected urethral disruption from pelvic trauma based on history +/- the observation of blood at the urethral meatus. If there are features complicating the patient's case, such as recent urethral surgery or a known urethral stricture, consider consulting a Urologist to perform the procedure. If someone has a urinary tract infection, consider if they truly need the procedure, and if so, proceed as indicated. Equipment
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