OFFICE
ENDOMETRIAL BIOPSY
Dysfunctional Uterine
Bleeding
Risk Factors for
Endometrial Ca
Algorithm for Abnormal Vaginal
Bleeding
About this Document
·
Dysfunctional
Uterine Bleeding (DUB): Abnormal uterine
bleeding in absence of pelvic pathology.
Only some of these will require biopsy.
·
Risk Factors for Endometrial Carcinoma: Most of these will require endometrial
biopsy.
1.
Obesity
2.
Diabetes
mellitus – 2.8 fold increased endometrial Ca risk.
3.
Polycystic
ovarian syndrome – chronic anovulation
4.
Long estrogen
exposure: unopposed estrogen, early
menarche, late menopause, nulliparous or infertile women.
5.
Tamoxifen use –
especially over 2 years
6.
Increasing
age. Peak incidence of endometrial Ca
at age 60
7.
Other associated
cancers – breast, ovary, colon.
8.
Previous pelvic
irradiation.
9.
Endometrial
cells on pap smear associated with endometrial Ca over 50%
of time.
1.
Postmenopausal
bleeding. 7% of these will have
carcinomas.
·
>2 years
after last period
·
>6 mo. after
rise in FSH.
2.
Perimenopausal
bleeding with increased flow, decreased menstrual interval or intermenstrual
bleeding.
3.
On tamoxifen
with abnormal bleeding.
4.
Abnormal pap
smear. Always wait for pap smear
results, as this may change management. [1]
·
Postmenopausal
– any endometrial cells.
·
Premenopausal –
atypical endometrial cells.
5.
Endometrial
hyperplasia followup after hormonal therapy (3-6 mo.)
6.
Some dysfunctional uterine bleeding ( see flow
chart)
Dysfunctional
Uterine Bleeding
after History, Physical
and Special Studies
< 40 and Low Risk > 40 +
Risk Factors
Endometrial Biopsy
Infection
Hyperplasia
Atypia
Ca in Situ
Carcinoma
Endometrial Biopsy and consider Referral
Algorithm for Management of Abnormal Vaginal Bleeding [2]
Abnormal Vaginal
Bleeding
Office Endometrial
Biopsy
Unable to perform or insufficient sample
Appropriate management or referral
Low Risk for Ca High Risk for Ca
or
Endometrial Aspiration
Biopsy
Introduction
Endometrial biopsy should
be one of the most frequently performed procedures in the practice of women's health. New techniques
have made the procedure safe and cost-effective to perform in the office.
Pipette aspiration biopsy is as specific and sensitive for diagnosis of
pathology as D&C, and gives adequate results 87-96% of the time. [2, 3] Some studies find it superior to
D&C [4], and it is preferred by some women to
transvaginal ultrasound (TVUS). [5]
Limitations of the endometrial biopsy must be
considered. If the endometrium is less
than 4 mm. on TVUS, only 27% of samples will be adequate [6],
therefore it should not be done. In the younger
reproductive age woman who has vaginal bleeding not resolved by hormonal manipulation and
the biopsy is benign, consideration should be given to D&C or
hysteroscopy. If an adequate sample is not obtained in the menopausal woman whose
endometrium is atrophic, further diagnostic workup is indicated (see algorithm).
1. Differentiating causes of abnormal uterine
bleeding
·
ovulation/anovulation
·
hormone replacement therapy adjustment
·
malignancy/hyperplasia
2. Infertility evaluation
·
short luteal phase determination
·
ovulation/anovulation
3. Prior to hormone replacement in woman at
risk for uterine cancer.
4. Followup to previous diagnosis of
adenomatous hyperplasia or atypia
5. Evaluation of an enlarged uterus (in conjunction with ultrasound examination)
1.
Pelvic inflammatory disease/cervicitis
2.
Pregnancy
3.
Cervical stenosis (relative)
4.
Coagulation disorders (relative)
Preoperative evaluation and preparation
1.
The procedure is
explained to the patient and informed consent is obtained.
2.
A non-narcotic oral analgesic may be offered to the patient one hour
prior to the procedure (e.g. Ibuprofen 600-800 mg).
3.
A sanitary pad
should be available for possible use after the procedure.
4.
Antibiotic prophylaxis is indicated in those patients with prosthetic
heart valves. It is not needed in
patients with murmurs or mitral valve prolapse.
5.
Continuous
verbal support and a gentle technique will go a long way in relieving the
patient's fear and discomfort.
There are various
techniques for obtaining endometrial tissue. Sterile gloves and speculum are
not necessary in a "no touch" technique is used. The cervix is cleaned with antiseptic and the sterile
sampling device is inserted through the cervical os without touching the
vulva or vaginal side walls. The clinician does not touch the part of the
sampler that is placed into the uterus. Drapes are not necessary if this procedure is followed.
1.
sterile gloves
(optional)
2.
vaginal speculum (preferably Graves)
3.
antiseptic for
the cervix (e.g. povidone)
4.
Topical hurricaine spray
5.
endometrial
sampler device (Pipet) or Pipelle (Unimar, Connecticut)
6.
tenaculum (optional), uterine sound (optional)
7.
long ring
forceps and gauze sponges
8.
scissors
9.
formalin sample
bottle with labels
The Pipet Curet endometrial suction curette (Milex Products, 5915 Northwest Highway,
Chicago, Ill. 1-800-621-1278) may be used to obtain an endometrial sample without the necessity of an external vacuum
source and may be more successful in a
patient with a stenotic os. The Pipet Curet comes in 2 diameters, 3 mm
and 4 mm, and consists of an outer sheath with a circular curette opening
proximal to the closed distal tip and an
internal piston which is used to create negative pressure within the
sheath of the instrument. These units are inexpensive and require very little
office set-up. The diagnostic accuracy is at least equal to the D&C except
for the diagnosis of endometrial polyps and submucous fibroids.
Procedure
1.
Do a bimanual exam.
2.
Insert a vaginal speculum and visualize the cervix.
3.
Cleanse the cervix and apply antiseptic.
4.
Apply topical hurricaine spray to cervix if a tenaculum is
to be used.
5.
2% xylocaine 5 ml. instilled transcervically is shown to
reduce pain. It is not used routinely[7]
6.
Consider use of a tenaculum to bring the uterus in line
with the sampling pipette. The chance
of posterior penetration or perforation is reduced.[7]
7.
With the piston of the Pipet Curet fully advanced to the
distal tip of the sheath, the device is introduced through the cervical
canal into the uterine cavity up to the fundus usually without the need
for a tenaculum. The depth of the uterus is documented. If less than 6-8 cm., consider a uterine
sound to open the internal os. A
tenaculum is placed on the cervix if necessary.
8.
The sheath is stabilized with one hand and the piston is
drawn back completely in one continuous motion to create negative pressure
within the lumen. The piston
will remain in this position when released.
9.
The sheath is rotated between the thumb and index finger
and moved in and out between the fundus and the internal os three or four
times. These combined actions pass the curette opening through
helical arc against the walls of the uterus. During this passage, the negative pressure within the sheath
draws the endometrial tissue into the curette opening where it is cut away
and carried into the sheath lumen. The lumen of the curette should be filled
as completely as possible with tissue.
10.
The Pipet Curet is withdrawn. If sufficient tissue is
present the distal tip is cut off with scissors and the sample
is expelled into formalin by advancing the piston into the sheath. Consider further passes with the device if
there is insufficient tissue.
11. The
speculum is removed from the vagina.
12.
In patients who are post menopausal without
hormonal replacement therapy, a significant number of
biopsy specimens are insufficient for histologic study. The insufficient
samples represent the small amount of tissue present in the endometrial
cavity. See algorithm
to determine how to proceed.
Indications
for D&C or Hysteroscopy after endometrial biopsy include:
1.
Inability to evaluate the endometrium due to cervical strictures or
stenosis or other mechanical obstruction.
2.
Suspected malignancy despite an endometrial biopsy report of benign
findings or adenomatous hyperplasia.
3.
Persistent bleeding or spotting after a benign
endometrial biopsy report.
4.
Insufficient tissue for diagnosis in high
risk patients.
5.
D&C can be avoided in low risk patients (see risk factors) if transvaginal ultrasound shows endometrial
thickness =/< 4 mm.
1. The patient is asked to
remain supine following endometrial biopsy for 10-15 minutes to assess for vasovagal reaction.
2. Painful
uterine cramps usually subside rapidly or are relieved by NSAIDS.
3. The patient may be discharged
from the clinic if heavy bleeding is not observed and the vasovagal reaction, if occurring,
has stopped.
4.
Sexual relations may be resumed in two to three days or
after bleeding has stopped.
5.
The patient is instructed to report any fever or cramping
after 48 hours or bleeding 24-48 hours that is heavier than a normal menses.
Complications of endometrial
biopsy
1.
Infection: Bacteremia, septicemia and
endocarditis have been reported following endometrial biopsy.
2.
Perforation: Reports indicate a 0.1 - 1.3%
risk for uterine perforation. Patients suspected of perforation should be
hospitalized and observed for bleeding complications and infection.
3.
Bleeding: Excessive uterine bleeding may occur following endometrial biopsy,
especially with undiagnosed perforation or coagulation disorder.
4.
Syncope: 5% or
less of patients will have a vaso-vagal reaction after the procedure. This usually improves with supine position,
leg elevation, and, if necessary, atropine.