Endometrial Biopsy

Endometrial Biopsy
By:Lianne Beck, MD
Assistant Professor
Emory Family Medicine

Indications
* Abnormal uterine bleeding: postmenopausal bleeding, malignancy/hyperplasia, ovulation/anovulation, HRT
* Evaluation of patient with one year of presumed menopausal amenorrhea
* Assessment of enlarged utereus (combined with US and neg HCG)
* Monitoring adjuvant hormonal tx (tamoxifen)
* Evaluation of infertility
* Abnormal Pap smear with atypical cells favoring endometrial origin (AGUS)
* Follow-up of previously diagnosed endometrial hyperplasia
* Cancer screening (e.g., hereditary nonpolyposis colorectal cancer)
* Inappropriately thick endometrial stripe found on US
* Endometrial dating


Contraindications
* Pregnancy
* Acute PID
* Clotting disorders (coagulopathy)
* Acute cervical or vaginal infections
* Cervical cancer

Conditions Possibly Prohibiting Endometrial Biopsy
* Morbid obesity
* Severe pelvic relaxation with uterine descensus
* Severe cervical stenosis

Equipment
* Non-sterile Tray (Examination for Uterine Position)
o Nonsterile gloves
o Lubricating jelly
o Absorbent pad to place beneath the patient on the examination table
o Formalin container (for endometrial sample) with the patient's name and the date recorded on the label
o 20 percent benzocaine (Hurricaine) spray with the extended application nozzle *
* Optional Equipment
* Sterile Tray for the Procedure
o Sterile gloves
o Sterile vaginal speculum
o Uterine sound
o Sterile metal basin containing sterile cotton balls soaked in povidone-iodine solution
o Endometrial suction catheter
o Cervical tenaculum
o Ring forceps (for wiping the cervix with the cotton balls)
o Sterile 4 x 4 gauze (to wipe off gloves or equipment)

Procedure
* Patient in lithotomy position, bimanual exam to determine uterine size, position, uterocervical angulation.
* Insert sterile speculum.
* Clean cervix with povidone-iodine solution.
* Sound the uterus. If needed, use tenaculum, grasping the anterior lip of cervix, for counter-traction.
* Pull outward with tenaculum to straighten the uterocervical angle.
* Insert sound to the fundus, using steady moderate pressure. Usually measure 6-8 cm.

* May need cervical dilators if sound will not pass through internal os.
* Insert sterile endometrial biopsy catheter tip into cervix to the fundus, or until resistance is felt, avoiding contamination from nearby tissues.
* Fully withdraw the internal piston on the catheter, creating suction at the catheter tip.
* Obtain tissue by moving with an in-and-out motion and using a 360-degree twisting motion. Allowing tip to exit endometrial cavity will lose suction.
* Once the catheter fills with tissue, withdraw it, and place sample in the formalin container, by pushing piston back into the catheter tip. Make a second pass if necessary.
* Remove tenaculum, apply pressure to any bleeding, then remove speculum.
Follow Up
* Normal endometrial
o Proliferative (estrogen effect or preovulatory)
o Secretory (progesterone effect or postovulatory)
* Atrophic endometrium
o Hormonal therapy
* Cystic or simple hyperplasia w/o atypia
o Progress to cancer is < 5%
o Hormonal manipulation (medroxyprogesterone [Provera], 10 mg daily for five days to three months)
o Close follow-up w/ repeat EBx in 3-12 months
* Atypical complex hyperplasia
o Progresses to cancer in 30 to 45 %
o D&C to exclude endometrial cancer
o Consider hysterectomy for complex or high-grade hyperplasia.
* Endometrial carcinoma
o Referral to a gynecologic oncologist for definitive surgical therapy.

Pitfalls/Complications
References

Endometrial Biopsy.ppt