Office Endometrial Biopsy

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• Endometrial suction curette
  • Low pressure suction devices, e.g., Pipelle® and Endocell™ are the most commonly used
    • Flexible plastic cannula with 3mm diameter with inner piston, which creates suction
      when pulled back
    • Higher pressure devices, e.g., Karman and VABRA® are rigid and not as commonly used, may cause discomfort to patient
  • When there is clinical suspicion for endometrial polyps or submucosal leiomyomas, sonohysterography or hysteroscopy will enable better detection of lesions
  • Positive tests are more accurate for ruling in disease than a negative test result is for ruling it out: the posttest probability of endometrial cancer was 81.7% (95% confidence interval, 59.7–92.9%) for a positive test result and 0.9% (95% confidence interval, 0.4–2.4%) for a negative test result
• Indications
  • Evaluation of abnormal uterine bleeding
  • Evaluation of postmenopausal bleeding
  • Confirmation of chronic uterine infection
  • Part of work-up for Atypical glandular cells on Pap test
  • Monitoring of women with known endometrial pathology including endometrial hyperplasia
  • Screening in women with high risk for endometrial cancer including Lynch syndrome
• Contraindications
  • Profuse bleeding (relative)—may not get adequate sample
  • Viable intrauterine pregnancy (absolute)
• Negative biopsy results with continued abnormal bleeding requires further evaluation such as repeat biopsy or hysteroscopy / D&C

Equipment

• Tenaculum: to stabilize the cervix and uterus
• Aspiration device
• Speculum
• Dilator: to open cervix in case of stenosis
• Formalin container for specimen
• Betadine or alternative to clean cervix/vagina

Office Endometrial Pre-evaluation

• Informed consent
  • Risks and alternatives
  • Consider/offer prophylactic pain medication (NSAIDS)
  • Consider/offer paracervical block, especially if dilation is needed due to cervical stenosis
  • Antibiotics are not necessary

Steps of Office Endometrial Biopsy

1. Assemble all equipment
2. Conduct timeout
   1. Patient
   2. Procedure
   3. Confirm negative pregnancy test
3. Bimanual exam for size and position of uterus
4. Insert speculum and clean cervix with Betadine® or alternative in case of allergy
5. Insert the pipelle gently through the cervix into the uterus until resistance is met (fundus)
6. If unable to pass the device, place a tenaculum on the anterior lip of the cervix to straighten the angle between the cervix and uterus
   1. If still unable to pass the device through the cervix, use of a cervical dilator or os finder may be required
7. Sound the uterus with the sampling device. Average length is 6 to 8 cm for a normal sized uterus
8. Withdraw the inner piston of the device to create suction
9. Rotate and twist (corkscrew) gently while moving the device in and out through all quadrants of the uterine cavity
10. Once tube is filled with tissue, remove the device and push the inner piston into the tube to empty the endometrial sample directly into a formalin container
    • Multiple uterine passes with the device may be needed to get an adequate specimen
    • Make sure the tip of the device does not touch the formalin if multiple passes are needed
11. Once adequate specimen obtained remove tenaculum
    • Apply hemostatic measures if needed
    • Remove speculum
    • Ensure that the specimen cup with the tissue sample is labeled properly
12. No specific follow-up is needed for the procedure

Office Endometrial Biopsy: Stenotic Cervix

• Common in postmenopausal women or women with previous cervical procedures such as LEEP or cryo
• Troubleshooting options:
  • Cervical dilators
    • Consider paracervical block
  • Pre-procedure misoprostol to soften the cervix
    • No ideal regimen
    • 200 to 400 mcg vaginally the night before the procedure
  • Pre-procedure placement of laminaria
    • One 3-mm laminaria is adequate

Complications of Office Endometrial Biopsy

• Vasovagal reaction
  • Relatively common
  • Typically responds to conservative measures
• Uterine perforation
• Infection Pain/cramping
• Bleeding—rarely clinically significant
• Inadequate sample—more common in postmenopausal women

Follow Up

• After initial discomfort patients typically do well
• May need NSAIDS again later that day
• See patient back to review pathology report in 7-14 days
• If pathology does not match the clinical picture consider further evaluation with H/S, D&C or sonohysterogram
• If symptoms continue despite evaluation and treatment, consider further evaluation

Contributing Authors

• Nikki B. Zite, MD, MPH Professor, Residency Program Director Obstetrics and Gynecology The Department of Obstetrics and Gynecology The University of Tennessee Graduate School of Medicine
• Eve Espey, MD, MPH Professor and Chair University of New Mexico

Developed in association with the Society of Family Planning.