Endometrial Biopsy

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Endometrial Biopsy

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Introduction

Endometrial biopsy (EMB) is a safe and effective method for diagnosing various endometrial abnormalities. It provides a minimally invasive assessment of the endometrium that may be used as an alternative to dilatation and curettage or hysteroscopy. Modern suction catheters have made this outpatient technique easy to learn and perform. It provides part of a cost-effective diagnostic workup for abnormal uterine bleeding, and may be considered part of an evaluation that could include hysteroscopy, dilatation and curettage, or transvaginal ultrasonography. Although a negative study is reassuring, further evaluation is warranted if a patient demonstrates continued abnormal bleeding. 
Catheter-type EMBs are safe. Uterine perforations are rare unless the device is forced. Postoperative infection is rare but may be prevented with the use of prophylactic antibiotic therapy such as doxycycline (100 mg) administered twice daily for 4 days after the procedure. The patient may also be premedicated with a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (600 to 800 mg) the night before and morning after or at least 1 hour before the procedure to decrease the cramping associated with the sampling. Bacterial endocarditis prophylaxis is no longer recommended (see Appendix C). Intraoperative and postoperative cramping is a frequent side effect of the procedure. 
Some physicians prefer to apply a tenaculum and give slight countertraction toward the operator. Although a tenaculum helps stabilize the cervix, it also causes additional pain and bleeding. It may also be used to straighten a markedly anteverted or retroverted uterus and may make the procedure safer in this setting. If used, it should be applied to the anterior lip of the cervix (not in the os), with the teeth in a horizontal plane. 
Because of the stenosis of the cervical os that develops in low-estrogen states, it can be difficult to perform an EMB in postmenopausal women. Elderly women can have a laminaria (i.e., thin piece of dried, sterile seaweed) placed in the cervix in the morning and then return in the afternoon to have the swollen (now moistened) laminaria removed immediately before the procedure. A cervical dilator may also be used when the EMB catheter cannot be passed through the internal os in postmenopausal women. 
Topical benzocaine solution (i.e., Hurricaine solution) may be applied to the cervix to decrease the pain from entry of the curette into the uterus. A cervical or paracervical block also may be used. For a cervical block, inject 1% to 2% lidocaine with epinephrine submucosally in the center of each cervical quadrant. Anesthesia may be applied at any time during the procedure. Some data suggest that instilling 5 mL of 2% lidocaine into the uterine cavity before endometrial biopsies significantly decreases the pain of the EMB. 

Equipment

  • Catheter-type devices

    • Unimar PIPELLE (Pipelle de Cornier), which can be ordered from CooperSurgical, Inc., Shelton, CT. Phone: 1-800-243-2974. Web site: http://www.coopersurgical.com/.

    • Wallach Endocell Endometrial Cell Sampler (20-piece box), which can be ordered from Wallach Surgical Devices, Inc., 235 Edison Road, Orange, CT 06477. Phone: 203-799-2000; fax: 203-799-2002. E-mail: wallach@wallachsurgical.com. http://wallach@wallachsurgical.com/.

Indications

  • Examination for abnormal uterine bleeding (to rule out endometrial hyperplasia or cancer)

  • Workup for atypical glandular endometrial cells seen on the Papanicolaou (Pap) smear

  • Monitor unopposed estrogen therapy for the development of hyperplasia

  • Endometrial dating

  • Infertility evaluation

  • Postmenopausal bleeding

Contraindications

  • Pregnancy or suspected pregnancy

  • Acute pelvic inflammatory disease

  • Acute cervical or vaginal infections

  • Uncooperative patient (relative contraindication)

  • Pregnancy

  • Clotting disorders (coagulopathy)

  • Cervical cancer

  • Morbid obesity (relative)

  • Severe pelvic relaxation with uterine descensus (relative)

  • Severe cervical stenosis (relative)

The Procedure

Step 1

Explain the procedure, and obtain informed consent. Perform a pelvic examination. Determine the size and position of the uterus. Apply povidone-iodine to the ectocervix (if not allergic) and external os with a swab or cotton ball. 
  • PITFALL: Check for masses or structural abnormalities, cervical stenosis, or signs of infection that may make the procedure more difficult or impossible.

Step 2

Sound the uterus (normal depth is 6 to 9 cm) if desired. Some devices are graduated and may be used in place of a sound. 
  • PITFALL: When inserting a sound, apply firm, steady forward pressure to pass through the tightly closed internal os of the upper cervix. Be prepared to immediately pull back after the internal os is penetrated, or the tip of the sound can be thrust forward against the upper uterus and perforate the opposing wall. Perforations also can occur through the thin lower uterine segment. Placement of a tenaculum in difficult cases and straightening of the uterocervical angle can help reduce perforation after the sound passes through the internal os.

Step 3

With the central piston fully inserted into the sheath (do not pull out), the endometrial sampler is inserted into the os until it reaches the fundus. Note the depth of insertion. Do not touch the end of the device that is to be inserted or allow it to touch the patient except at the os. 
  • PITFALL: If strong resistance is encountered, consider repeat sounding the uterus. If still unable to enter the endometrial cavity with the EMB catheter, abort the procedure. Forcing the catheter may result in uterine perforation.

  • PITFALL: If the catheter bends excessively, apply a small amount of torque to the catheter. This causes it to flex less.

Step 4

Holding the sheath steady, pull back on the piston until it stops. This creates negative pressure inside the curette. Leave the piston fully retracted. 

Step 5

Roll or twirl the sheath laterally between the thumb and fingers while simultaneously moving the sheath tip back and forth between the fundus and internal os. Tissue should move into the sheath as the operation progresses. Complete the maneuver three or four times to obtain the sample. 
  • PITFALL: Do not allow the hole in the tip to emerge from the cervix, or all of the suction will be lost.

Step 6

Remove the sampling device, and cut off the distal tip. Although this step may be skipped, cutting the tip off will cause the least distortion of the tissue when the sample is pushed into the formalin. 

Step 7

Slowly push the piston completely into the sheath to expel the sample into the fixative. Remove the speculum, and allow the patient to sit up and rest before dressing. 
  • PITFALL: Do not force the tissue out of the sampling hole without cutting the tip off because this may distort the histologic sample.

Complications

  • Pain (especially cramping)

  • Spotting

  • Infection

Pediatric Considerations

This procedure is rarely performed in the pediatric population. 

Postprocedure Instructions

Instruct the patient to take a NSAID or acetaminophen if they have any discomfort after the procedure. Explain that some vaginal bleeding or spotting is common following the procedure. Have the patient call if she experiences heavy bleeding, pain in the lower abdomen or vagina, or a foul-smelling vaginal discharge. Finally, tell the patient not to place anything in her vagina and to avoid intercourse for 1 week following the procedure. 
Follow-up is often dictated by the test results. 
  • Atrophic endometrium: Hormonal therapy may be considered for patients with atrophic endometrium. Persistent vaginal bleeding should warrant further diagnostic workup.

  • Cystic or simple hyperplasia: Progresses to cancer in fewer than 5% of patients. Most individuals with simple hyperplasia without atypia can be managed with medroxyprogesterone (Provera), 10 mg daily for 5 days to 3 months, or with close followup.

  • Atypical hyperplasia: Considered a premalignant lesion that can progress to cancer in 30% to 45% of women. A dilation and curettage (D&C) procedure to exclude the presence of endometrial carcinoma is recommended.

  • Endometrial carcinoma: Consider referral to a gynecologic oncologist for definitive surgical therapy.

Coding Information and Supply Sources

Bibliography

Archer DF, Lobo RA, Land HF, et al. A comparative study of transvaginal uterine ultrasound and endometrial biopsy for evaluating the endometrium of postmenopausal women taking hormone replacement therapy. Menopause .  1999;6:201–208. [View Abstract]
Bakour SH, Khan KS, Gupta JK. Controlled analysis of factors associated with insufficient sample on outpatient endometrial biopsy. Br J Obstet Gynecol .  2000;107:1312–1314. [View Abstract]
Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA .  1993;269:1823–1828. [View Abstract]
Cicinelli E, Didonna T, Schonauer LM, et al. Paracervical anesthesia for hysteroscopy and endometrial biopsy in postmenopausal women: a randomized, double-blind, placebo-controlled study. J Reprod Med.  1998;43:1014–1018. [View Abstract]
Dijkhuizen FP, Mol BW, Brolmann HA, et al. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer .  2000;89:1765–1772. [View Abstract]
Mishell DR Jr, Kaunitz AM. Devices for endometrial sampling: a comparison. J Reprod Med.  1998;43:180–184. [View Abstract]
Oriel KA, Schranger S. Abnormal uterine bleeding. Am Fam Physician.  1999;60:1371–1380. [View Abstract]
Tahir MM, Bigrigg MA, Browning JJ, et al. A randomized controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. Br J Obstet Gynaecol.  1999;106:1259–1264. [View Abstract]
Trolice ME, Fishburne C Jr, McGrady S. Anesthetic efficacy of intrauterine lidocaine for endometrial biopsy: a randomized double-masked trial. Obstet Gynecol.  2000;95:345–347. [View Abstract]
Zuber TJ. Endometrial biopsy. Am Fam Physician .  2001;63:1131–1135, 1137–1141.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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