Dysfunctional Uterine Bleeding

Risk Factors for Endometrial Ca

Who to Biopsy?

Algorithm for Abnormal Vaginal Bleeding

Endometrial Aspiration Biopsy






Indications for D&C

Postop Care



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.


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Who to Biopsy?

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


No Pathology Pathology




Ca in Situ
























Treatment Failure



















Treatment Failure























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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

Normal with ongoing bleeding

Normal with no symptoms


















Appropriate management or referral


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Low Risk for Ca High Risk for Ca



















Transvaginal Ultrasound


Negative Positive





















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D&C and/or Hysteroscopy


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Repeat Biopsy


Transvaginal Ultrasound


















Normal + Bleeding Persists

Normal with No Bleeding















> 4 mm. Endometrial Thickness

<4 mm. + Bleeding Persists

<4 mm. with No Bleeding















Endometrial Aspiration Biopsy



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).

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1. Differentiating causes of abnormal uterine bleeding


        hormone replacement therapy adjustment


2. Infertility evaluation

        short luteal phase determination


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)


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1.      Pelvic inflammatory disease/cervicitis

2.      Pregnancy

3.      Cervical stenosis (relative)

4.      Coagulation disorders (relative)


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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.


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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


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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.




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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.


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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.


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Postoperative Care

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.


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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.


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1.      Hatcher L. Endometrial biopsy: When and how? Canadian J of CME December 2003: 94-97.

2.      Brand A, et al. Diagnosis of endometrial cancer in women with abnormal vaginal bleeding. Journal SOGC 2000; 22(1): 102-104.

3.      Behnamfar F, et al. Diagnostic value of endometrial sampling with pipelle suction curettage for identifying endometrial lesions in patients with abnormal uterine bleeding. J of Research in Medical Sciences 2004; 3: 123-125.

4.      Dijkhuizen FP, Mol BW, Brolman HA, Heintz AP. The accuracy of endometrial sampling of patients with endometrial carcinoma and hyperplasia: a meta- analysis. Cancer. 2000 Oct 15; 89(8): 1765-72.

5.      Greiver, M. Endometrial biopsy. Canadian Family Physician 2000; 46: 308-309.

6.      Elsandabesee D, et al. The performance of pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic. J Obstet Gynaecol. 2005; 25(1): 32-34.

7.      Willacy H. Pipelle endometrial sampling (procedure). PatientPlus UK 2007; available online at .

8.      Kuntz C. Endometrial biopsy. Canadian Family Physician 2007; 53: 43-44.


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