Vasovagal reaction—IUD insertion, removal, and transcervical procedures in general may provoke a vasovagal response. The patient may experience transient (pre)syncope, nausea, hypotension, diaphoresis, or bradycardia. Should this occur, terminate the procedure and provide supportive care to the patient. Place her in a supine position and if necessary, elevate her lower extremities. If her symptoms persist, consider placing a paracervical block or removing the IUD. For the truly refractive vasovagal episode, atropine (0.4 mg intramuscular injection) may be given to the patient while assessing for uterine perforation and intra-abdominal bleeding.

Infection—Active infection or symptoms suspicious for infection are clear contraindications to IUD insertion. For patients who are at low risk for sexually transmitted infections (STI), the use of prophylactic antibiotics at the time of insertion confers no benefit and is not recommended [16]. An international study did confirm a transient increased risk of PID due to bacterial contamination at the time of IUD insertion. The first 20 days after an IUD is inserted is the time of greatest infection risk [17]. This suggests that resultant PID is due to the introduction of pathogens during device insertion and underscores the importance of sterile technique. A retrospective cohort study of 57,000 IUD insertions revealed that the risk of PID after device insertion is only 0.54 %. As encouraged by device manufacturers, many clinicians screen for gonorrhea and chlamydia in patients based on their STI risk. According to the CDC, the prevalence of chlamydia is highest among women 14–25 years of age and is approximately 3 %. In addition, the American College of Obstetricians and Gynecologists defines women with multiple sexual partners and those younger than 25 years old as “high risk” for STI. Therefore, for this group of women, it is advised and reasonable to perform STI screening on the day of IUD insertion. Same day screening and insertion increases contraceptive access and decreases the chance of unintended pregnancy. If an infection is detected, the patient and her partner should be treated and the IUD may remain in place [18].

Perforation—This complication usually occurs at the time of insertion and is prone to involve the fundus, lower uterine segment, and midline posterior wall. Perforation may also occur remote from IUD insertion as a result of uterine contractions. These perforations are usually in a different plane or trajectory of insertion and more commonly involve the cervix. Perforation is a rare event occurring in 1 out of 1,000 insertions or less in experienced hands. The risk of perforation is dependent upon provider experience and increases with a stenotic cervix, immobile uterus, and a markedly flexed uterus. A sudden inappropriate, loss of resistance, severe patient pain, or a large discrepancy between uterine depth and anticipated uterine length should trigger an evaluation for perforation. The instrument should be removed gently and the patient should be observed for hemorrhage. If the patient’s condition does not improve or there is a strong suspicion of intraperitoneal injury, swift surgical evaluation is necessary.

If uterine perforation occurs and the patient remains stable the clinician has two options: The procedure may be discontinued and the IUD inserted on a separate visit. Or, the IUD may still be inserted at the same visit, but care should be taken not to follow the previous tract. Although prophylactic antibiotics have been proven to be unnecessary for routine IUD insertion, when perforation occurs, the use of antibiotics is less clear since the procedure may have allowed passage of vaginal flora into the peritoneal cavity. In these instances, doxycycline (100 mg twice a day for 7 days) with or without metronidazole (500 mg twice a day for 7 days) may be considered [19, 20].

Expulsion—Expulsion of a device may occur even if the device was properly placed. Expulsion may be associated with pain and bleeding or the patient may be completely asymptomatic. Although it is a common practice to insert IUDs during a patient’s menses, the expulsion risk during the first 5 days of a cycle is 5 % compared to 2 % if inserted during the luteal phase [21]. The risk of expulsion is also greater when IUD insertion is performed immediately after uterine evacuation and the uterus is still enlarged [22]. On the other hand, expulsion rates may also increase with smaller uteri, length less than 6 cm, and with anatomic uterine aberrations. If an IUD is expelled, consider performing the second IUD placement under ultrasound guidance. Or, sonographically confirm correct placement immediately afterward, since a patient with one previous expulsion has a 30 % chance of subsequent expulsion [23].

Malposition—Ideally, the IUD should be located in the uterine fundus. Occasionally, IUDs are malpositioned and are located in the lower uterine segment or endocervix (versus a partially expelled IUD that is visible at the external os and should be removed), embedded within the myometrium, or rotated out of the uterine plane. Prior to removing or replacing the device, the clinician should note several things including: the type of device, if the patient is symptomatic and warrants device removal, if the malpositioned device is still providing effective contraception, and if the risk of removing the device, particularly in an asymptomatic patient, will increase the chance of unintended pregnancy. Specifically, there is limited data that suggests that due to their different mechanisms of action, malpositioned Copper IUDs within the endocervix, unlike their levonorgestrol counterparts [24], do not provide adequate contraception. One study noted a malpositioned Copper IUD located in the cervix is almost 14 times as likely to be associated with concomitant pregnancy [25]. Therefore, before removing a malpositioned device and/or inserting a new IUD, a clinician should assess for pregnancy and counsel the patient appropriately.

Removal of an IUD is usually straightforward and swift. A sterile speculum is placed and using a ring forceps, the strings are grasped and used to gently remove the device from the uterus. Occasionally, removal is more involved. A sharply flexed uterus can be tricky and may decrease necessary visualization and access. In these instances, gentle traction applied with a tenaculum straightens the utero-cervical junction and aids in device retrieval. In addition, IUD strings are sometimes missing or retracted into the uterine cavity or endocervix. In this case, an ultrasound may be helpful to confirm that the device remains within the uterus. If the device is not seen within the uterus, a plain film X-ray of the abdomen and pelvis may confirm device perforation.

Endocervical speculums and endocervical brushes can be used to visualize the cervical canal and gently tease the threads outward. Furthermore, IUD hooks are also available and should be used by experienced clinicians to extricate the device threads. If the device is still unable to be retrieved flexible or rigid hysteroscopy can be performed to guide the threads outward.

Endometrial sampling (ES) in the office is a simple, safe, well tolerated, and cost-efficient method to obtain uterine tissue for histology diagnosis. As early as the 1920s, in-office endometrial biopsy (EMB) was lauded for the advantages of avoiding general anesthesia and allowing the patient to quickly resume her normal daily function.

The original Novak and Randall curettes are rigid, metal sheaths with an outer diameter of 4.2–3 mm respectively. The most distal end contains a small serrated or beveled lateral opening and the most proximal end attaches to an aspirator that provides suction. In 1968, Jensen described a modification. Using a rigid 3 mm cannula attached to 600 mmHg of vacuum suction, an in-office vacuum-abrasion technique, or Vabra, aspirator was introduced. Despite the small outer diameter and apparent effectiveness, the Vabra device and technique did not gain widespread office adoption. Significant patient discomfort and the reliance upon a machine to produce sufficient vacuum suction caused many clinicians to return to the operating room to perform a standard dilation and curettage until a superior in-office device came to market. Additional electronic and vacuum syringe devices were trialed but they too had limited clinical acceptance [26].

Today, the original curettes and aspirators have mostly been replaced with flexible, 2–4 mm, plastic pipelles that are very well tolerated by patients. The newer pipelle biopsy device is disposable and does not require an aspirator. Instead, a vacuum is created by withdrawing the inner piston from the pipelle cannula. This creates a negative pressure that draws the endometrial tissue into the pipelle channel. No additional personnel or equipment is necessary to perform the simple procedure. There are a number of pipelle kits available today—all with varying accessories such as additional suction syringes, multi-perforated channels, and even cytology abrasion brushes.

Given the numerous and varied indications for endometrial sampling, EMB is one of the most common procedures encountered in a gynecology office. The procedure’s efficacy for detecting malignancy has been investigated numerous times. Two separately conducted, large reviews—revealed that EMB has high accuracy in diagnosing endometrial cancer especially if the endometrial process is global and if an adequate specimen is obtained. If the malignancy occupies less than half of the endometrial surface, however, the cancer may not be detected by a blind, random, cavity sampling. Therefore, the procedure is more accurate at confirming a uterine cancer diagnosis than excluding an intrauterine malignancy [27, 28]. In summary, if a patient has a negative EMB result but continues to have symptoms, further clinical evaluation is warranted with either saline infusion sonography or office diagnostic hysteroscopy (Chaps. 6 and 7).

EMB should not be performed in cases of pregnancy, coagulopathy, or known pelvic infection. If possible, avoid scheduling a biopsy when the patient is having heavy uterine bleeding as this may increase the risk of insufficient tissue sampling. In addition, EMB can interfere with an early, undiagnosed pregnancy. Therefore, it should not be performed more than 14–16 days after ovulation.

Normally, the Bartholin glands are pea-sized, non-palpable glands located bilaterally at the 5 and 7 o’clock position of the posterolateral aspect of the vaginal orifice. The gland drains into a 2.5 cm long duct and the duct drains into the space between the hymen and the labia minora (see Fig. 5.4). Occasionally, trauma, inflammation, or obstruction of the orifice causes the ducts to dilate. Many of these dilations range from 1 to 3 cm in diameter and are commonly referred to as a Bartholin cyst, although it is actually an obstructed and dilated duct. An asymptomatic Bartholin cyst does not require treatment and is not an infection. One exception to this is a Bartholin cyst in a 40-year-old, or older, woman or a woman with Paget’s disease of the vulva. For these patients, incision, drainage, and additional biopsy of the gland is recommended to exclude carcinomas such as adenocarcinoma and squamous cell carcinoma [30, 31].

Sometimes, the duct rapidly enlarges over just a few days and causes significant pain. In addition, the dilated duct may become infected and progress to a polymicrobial abscess characterized by a fluctuant vulvar mass (that may extend past the vestibular area), severe pain, warmth, tenderness, edema and/ or cellulitis (see Fig. 5.5). A symptomatic Bartholin cyst or an overt Bartholin abscess requires intervention and this can be safely performed in the office. Definitive treatment for recurrent duct dilation or abscess formation is excision of the gland but given the risk of bleeding and need for adequate anesthesia, this procedure is usually performed in the operating room. It is also important to note that unusual or unremitting Bartholin gland infections warrant further evaluation. Immunocompromised and diabetic patients are more susceptible to rare, but life threatening, necrotizing subcutaneous infections which require immediate surgical excision and debridement.

In addition to malignancy, other benign vulvar masses can be found in the area of the Bartholin gland and should be considered prior to treatment. The differential diagnosis of these lesions is listed in Table 5.1. Simple Bartholin gland cysts do not require antibiotic treatment. For a cyst that is already draining, warm compresses and Sitz baths alone can be therapeutic. For patients affected by recurrent ductal dilation, abscess, extensive cellulitis, concomitant STI, pregnancy, immunosuppression, hospitalization, or increased risk of methicillin-resistant staphylococcus aureus infection, administer dual treatment with clindamycin (300 mg by mouth four times a day for 7 days) and amoxicillin–clavulanate (875 mg by mouth two times a day for 7 days) [32]. Antibiotic treatment should be reevaluated and tailored based on microbiology findings and correlation with the patient’s clinical condition.