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.

Equipment

1. Large vaginal speculum
2. Nonsterile gloves, gown, mask, and eye protection
3. Antiseptic solution
4. Cotton balls
5. Ring forceps
6. Uterine sound
7. Single-toothed tenaculum
8. Topical benzocaine gel (20%) or benzocaine spray
9. Buffered formalin specimen containers with patient identification labels (two)
10. Endometrial Aspirator 

Procedure

1. Ensure Pap is up to date. If not, obtain Pap smear before performing the endometrial biopsy.
2. Obtain consent (indication/risks/alternative options, ensure understanding and answer any questions) *Risks: Uterine perforation, excess uterine bleeding, false negative from missing areas with pathology, vasovagal response and/or pain immediately post-procedure, infection
3. Optional: The patient may take an NSAID 30-60 min prior to the procedure to decrease cramping/pain from the procedure.
4. Timing of the procedure: Best to be done when there is no active bleeding, if possible.
5. Positioning: Position the patient in dorsal lithotomy.
6. Don gloves, gown, mask, and eye protection (universal precautions)
7. Perform a a bimanual exam to determine orientation and size of uterus
8. Insert large speculum. Visualize the cervix and clean off any mucus or debris using antiseptic solution, cotton balls, and ring forceps. 
9. Use the uterine sound to dilate the cervical os
10. Proceed with endometrial biopsy. Technique will depend on endometrial biopsy instrument. Avoid contaminating instrument by touching vaginal side walls. Generally insert tip of instrument to uterine fundus and create suction, drawing up endometrial tissue. Continue to move catheter about the uterus, sampling circumferentially from a variety of areas. Enough sample is acquired when about half of the catheter is filled with endometrial tissue.
11. After the procedure is done, the patient should remain supine for 10 minutes.
12. Advise patients to return for assessment if they develop fever, bleeding heavier than a normal period, or cramping >48 hours after the procedure (the patient may take NSAIDs to manage cramping/discomfort in the first 48 hours).
13. Document the procedure.

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:

1. Pregnancy
2. Current or recent (within the past 3 months) sexually transmitted infection
3. Abnormal vaginal bleeding that is not yet diagnosed
4. A structural uterine abnormality

Ruling out pregnancy, performing STI screening, and ensuring a woman is up to date with her Pap testing are important before inserting an IUD. 

Equipment

1. Prepackaged IUD
2. Speculum
3. Sterile basin with cotton balls moistened with a water-based antiseptic (ex: chlorhexidine)
4. Ring forceps
5. Cervical tenaculum
6. Uterine sound
7. Nonsterile gloves (for bimanual examination before insertion procedure)
8. Sterile gloves (for IUD insertion phase)
9. Sterile towel to cover tray
10. Long suture scissors (to cut IUD threads after insertion)
11. NSAID, to be taken before procedure (optional)
12. Local anesthetic 
13. Cervical dilators may be needed in some nulliparous patients.

Procedure

1. Obtain consent (benefits, risks, alternatives, opportunity to ask questions, clarify understanding). The patient should be counselled on the cramping/discomfort/spotting that tends to go along with with insertion and removal. 
2. Preparation: Position patient in the dorsal lithotomy position, with appropriate draping. Prepare the needed equipment.
3. Visualize the cervix with the speculum.
4. Clean the cervix with the antiseptic solution.
5. Anesthetize the cervix.
6. Clamp the tenaculum to the anterior aspect of the cervix.
7. Sound the uterus, which means to take the uterine sound device and insert it through the cervical os to the top of the uterine funds. This is to measure the depth of the uterus. In a women with a stenosed cervix, you may need to use cervical dilators to accomplish this step. The uterine depth is normally between 6.5 and 8.5 cm. If outside of this range, do not insert the IUD as there is increased risk of complication.
8. Prepare and insert the IUD using an insertion tube (specific steps depend on the model)
9. Cut the strings so that they are 2-3 cm long protruding from the external cervical os (so that the woman can self-check her strings, but also because if they are shorter, they can feel like unpleasant pokey whiskers for a male sexual partner)
10. Remove the tenaculum and speculum
11. Book a pelvic ultrasound to assess IUD placement and book a follow-up appointment for a string check in about 1 month.
12. Document the procedure

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

1. Examination table appropriate for placing the patient in the lithotomy position, in a warm, well-lit examination room.
2. Various-sized speculums
3. Water-soluble lubricant
4. Nonsterile examination gloves.
5. Large swabs for gentle blotting of excess discharge.
6. Method for warming the speculum (warm water or speculum drawer warmer [light bulb]).
7. Wooden spatulas or plastic spatulas for ectocervical sample. Cytobrush for endocervical sample. As an alternative to taking two samples, a "broom" device can be used for ectodermal and endocervical samples 
8. Microscope slides, fixative (consult with reference laboratory performing cytology for their preference) or media for liquid-based testing. Materials and solutions for liquid-based Pap smears.
9. Appropriate patient identification, history forms to accompany Pap smear and other tests.
10. Culture or transport media and swabs as necessary for gonorrhea, chlamydia, herpes, fungal, and potassium hydroxide (KOH)/wet mount. (Although the Pap test does not test for STIs, this does not mean that the clinician cannot screen or sample discharge to look for evidence of an STI when performing a Pap).
11. Cervical tenaculum or cervical hook (rarely needed).
12. Ring forceps.

Anatomy of a cervix

1. The cervix is the distal portion of the uterus, and the external opening on the cervix is the external os. 
2. The area of the squamocolumnar junction marks the transition from the squamous epithelium of the exterior cervix to the columnar epithelium of the endocervical canal. The area is also called the transformation zone and it's where we want to sample the cells of the cervix for evidence of malignant transformation (this is the are where cancer arises when it does). 
3. In women who have had a hysterectomy for concerns of malignancy, the cervix is gone (because the whole uterus has been removed) and we sample cells from the blind pouch at the top in case there have been some cervical cells left behind.

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...

• Describe the use and risks of indwelling catheters versus intermittent catheter
  

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

• Urethral catheter
  • Size measure in French units, with one French being approximately 0.33mm in diameter. The standard size used in an adult is a 16 or 18 French.
  • There are different types of catheters, but the one the general practitioner needs to be comfortable inserting is the Foley catheter, which has 2 or 3 lumina. Urine flows through the main large lumen, a second is used to inflate the balloon to keep the Foley in-situ, and the occasional third lumen is used if fluid is to be irrigated into the bladder