Endometrial carcinoma is the leading cause of gynecologic malignancies in the United States. Unlike other malignancies, endometrial carcinoma presents early with the most common clinical symptom being uterine bleeding (including irregular menses, inter-menstrual bleeding, and postmenopausal bleeding, or PMB). Hence, the evaluation of PMB should have efficient and effective strategies to prevent a missed diagnosis of malignancy and to facilitate an early diagnosis for potentially curative treatment.Transvaginal ultrasound is appropriate to evaluate PMB initially. If imaging reveals an endometrial thickness of ≤4 mm, endometrial sampling is not warranted, given the high negative predictive value (>99%) of this finding for endometrial carcinoma. In women with persistent or recurrent bleeding, if blind endometrial sampling does not show endometrial hyperplasia or malignancy, further testing with hysteroscopy with dilation and curettage is indicated. However, in cases of PMB with an endometrial thickness of ≤4 mm on transvaginal ultrasound, little information can be gained from endometrial sampling alone as the chance of getting an adequate sample is low and malignancy is rare. For such patients, outpatient hysteroscopy has become a convenient and cost-effective procedure that may be done before an endometrial sampling.

The 19th World Rural Health Conference, hosted in rural Ireland and the University of Limerick, with over 650 participants coming from 40 countries and an additional 1600 engaging online, has carefully considered how best rural communities can be empowered to improve their own health and the health of those around them. The conference also considered the role of national health systems and all stakeholders, in keeping with the commitments made through the Sustainable Development Goals and the enjoyment of the highest attainable standard of health as one of the fundamental rights of every human being. This conference declaration, the Limerick Declaration on Rural Healthcare, is designed to inform rural communities, academics and policymakers about how to achieve the goal of delivering high quality health care in rural and remote areas most effectively, with a particular focus on the Irish healthcare system. Congruent with current evidence and best international practice, the participants of the conference endorsed a series of recommendations for the creation of high quality, sustainable and cost-effective healthcare delivery for rural communities in Ireland and globally. The recommendations focused on four major themes: rural healthcare needs and delivery, rural workforce, advocacy and policy, and research for rural health care. Equal access to health care is a crucial marker of democracy. Hence, we call on all governments, policymakers, academic institutions and communities globally to commit to providing their rural dwellers with equitable access to health care that is properly resourced and fundamentally patientcentred in its design.

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Background Men who have sex with men (MSM) and transgender women (TGW) in Rwanda are at higher risk than the general population of being subject to sexual and reproductive health (SRH) disparities pertaining to discrimination and marginalization. There is a significant gap in the literature concerning the experiences of MSM and TGW seeking SRH care, and the challenges that ensue. This study uses an MSM and TGW community-informed survey to analyze the barriers and recommendations to accessing SRH care. Methods A quantitative survey was administered to 134 MSM and TGW members of Hope and Care Organization (local non-government organization) in Rwanda to ascertain the magnitude of barriers and assign weight to the recommendations. Results COVID-19 induced restrictions, societal stigma, perceptions of community/local leaders, fear of disclosure/outing, and violence were found as barriers for both MSM and TGW (p≤ 0.05). Unsupportive policy/legal environment and long waiting times/delays were barriers specifically for the MSM whereas healthcare provider lack of knowledge was specifically for TGW (p≤ 0.05). More than 90% of respondents across both groups recommended unrestricted operation and capacity building of LGBTQI+ organizations, strengthening legal support, peer education & mentorship, mental health support/counsellors, increased community outreach, expansion of care to rural areas, sensitization of local, religious leaders and employers. Further specialized training for healthcare providers and more inclusive and accepting insurance were specific to MSM whereas increased media awareness and sensitization of the general population were specific to TGW. Conclusion This study highlights the unmet SRH needs of TGW and MSM while eliciting community informed recommendations that must drive policy change in Rwanda. The most emphasized recommendations include capacity building, economic support, accessible insurance, sensitization of healthcare providers and increased community outreach. The populations reiterated the need for SRH care to be holistic, highlighting the integral role of mental health care inclusion. Overall, psychosocial safety has been a pervasive theme that needs to be addressed to ensure SRH care delivery.

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