Women’s Health Workshop-The Basics2019 UPDATES included

Presented by: Laurel Hallock Koppelman, DNP, FNP-C, APRNAssistant Professor, OHSU School of Medicine

Disclosures

• I have nothing to disclose.

Shout out!!!

Aimee Holland, DNP, WHNP-BC, FNP-C, FAANP | Associate ProfessorDNP Program DirectorUAB School of Nursing | The University of Alabama at Birmingham•

You will find the videos on the University of Alabama at Birmingham School of Nursing website: http://www.uab.edu/nursing/home/technology-innovation/faculty-clinician-resources/gyn-np-procedures

•

• The simulation publications are in Nursing for Women's Health: A Journal for NPs: https://npwomenshealthcare.com/archives/

What we are planning on doing today and objectives

• Endometrial Biopsy

• Endometrial Polypectomy

• Vulvar Biopsy

Reasons for Endometrial Biopsy

• AUB– Amenorrhea for a year

with Post menopausal bleeding

– Thickened endometrium on ultrasound

– 45-menopause with heavy bleeding, >5 days heavy, <21 days between periods

– <45 yrs old with BMI > or = 30

• Cancer screening* (hereditary, colorectal, risk for hyperplasia )

• Endometrial dating • Infertility evaluation• Certain Cytology

Results

When not to do an endometrial biopsy

• ABSOLUTE contraindication– Pregnancy

• RELATIVE contraindications– Acute PID– Acute cervical or

vaginal infections.

– Clotting disorders– Anatomy

• Severe stenosis of cervical os

***You CAN do an EB with IUD in place!!!

Equipment Needed

• Sterile– Sterile gloves– Speculum– Uterine sound– povidone-iodine– Endometrial suction

catheter– Tenaculum– Ring forceps – Sterile 4 × 4 gauze– Sterile scissors

• Non-Sterile– gloves– Lubricating jelly– Chux pad– Sampling container– 20 percent benzocaine

(Hurricaine) spray with the extended application nozzle*

– Cotton swabs

How to perform endometrial biopsy

• https://cdnapisec.kalura.com/index.php/extwidget/preview/partner_id/2007921/uiconf_id/42460231/entry_id/1_m6b8avii/embed/dynamic

How to perform endometrial biopsy

• Negative HCG and consent signed.• Offer NSAIDS 20-30 minutes prior. • Perform bimanual exam. • Insert speculum. • Cleanse the cervix with betadine using ring forceps • Place tenaculum on anterior edge* (OPTIONAL)• Sound uterine depth (avg is 6 to 8 cm)• Insert endometrial biopsy catheter up to the fundus

How to perform endometrial biopsy

• Draw back internal tube on the catheter to make suction

• Move catheter in and out and twist 360 degrees as you do this w/o tip leaving endometrial cavity.

• Place sample in formalin jar• Remove tenaculum, apply pressure if bleeding and

remove speculum

Post-Procedure

• Remain recumbent for 15 minutes to prevent vagal response

• WARNING SIGNS– Fever– Cramping >48 hours– Foul smelling

discharge– Bleeding heavier than

a period

Endometrial biopsy PEARLS

• Can’t get through: – Change attachment of

tenaculem • Anterior vs Posterior

– Use dilator– Use OS finder– Still no luck:

• Get an ultrasound– What is blocking that

OS

• Always use a leg– Support don’t strike– Risk of perf

• Ibuprofen: cramping• Syncope:

– It happens

CERVICAL POLYP REMOVAL

• More fun!

Cervical Polyp Removal-Indications

• AUB/concern for malignancy• Noted on exam

– With or without symptoms• May cause irregular menstrual bleeding• Bleeding after or during sex

• Photo from https://planbwellness.com/what-are-cervical-polyps/

Cervical Polyp Removal: Contraindications

• Bleeding disorders• Pregnancy• Multiple polyps (too much bleeding)• Endometrial polyps (vascular) or thick stalk (too

much bleeding)

Cervical Polyp Removal: Supplies

• Non sterile gloves• Speculum• Betadine• Ring forceps• Formalin jars• Silver nitrate sticks

Cervical Polyp Removal

• https://cdnapisec.kaltura.com/index.php/extwidget/preview/partner_id/2007921/uiconf_id/42460231/entry_id/1_u8g3mix8/embed/dynamic

How to perform cervical polyp removal

• Verify neg HCG and consent. • Speculum to cervix and visualize polyp. • Cleanse with antiseptic• Grasp the polyp with the ring forceps and twist

the forceps around the stalk until it breaks off• Put tissue in formalin jar • Control bleeding with silver nitrate stick if needed

Vulvar biopsy indications

• Vulvar itching• Skin discoloration or texture changes• Vulvar bleeding• Vulvar lesion that does not heal

Vulvar biopsy Equipment

• 2 or 3mm skin punch• Lidocaine in a 3cc syringe with 27g needle• Sterile scissors• Skin forceps• Betadine• Antibiotic ointment

Vulvar Biopsy Procedure

• https://cdnapisec.kaltura.com/index.php/extwidget/preview/partner_id/2007921/uiconf_id/42460231/entry_id/1_ow6doefy/embed/dynamic

Vulvar biopsy procedure

• Consent• Cleanse area with betadine• Inject 1-2 cc of lidocaine in a wheal at site of

concern• Push 2mm or 3mm punch (no bigger or you will

need suture) into center and collect specimen• Send to pathology in jar of formalin• Apply abx ointment• Cover with dressing as needed

References

• THOMAS J. ZUBER, M.D., Saginaw Cooperative Hospital, Saginaw, Michigan. Endometrial biopsy. Am Fam Physician. 2001 Mar 15;63(6):1131-1135.

• https://ir.uiowa.edu/cgi/viewcontent.cgi?article=1036&context=fmrc