Endometrial Biopsy

1. See Also
   1. Endometrial Carcinoma
2. Indications for Endometrial Biopsy
   1. All Postmenopausal Bleeding
   2. Persistent or heavy perimenopausal bleeding
      1. High risk of Endometrial Cancer
      2. More than twelve months of bleeding
   3. Abnormal bleeding at any age (esp. >35) if high risk
   4. Very high risk asymptomatic women
      1. Morbid Obesity
      2. Unopposed Estrogen
      3. Chronic Anovulation
   5. Refractory Anovulatory Dysfunctional Uterine Bleeding
   6. Tamoxifen use
3. Contraindications
   1. Absolute Contraindications
      1. Pregnancy
      2. Acute Pelvic Inflammatory Disease
      3. Clotting disorder or coagulopathy
      4. Acute cervical infection
      5. Acute vaginal infection
      6. Cervical Cancer
   2. Relative Contraindications or complicating factors
      1. Morbid Obesity
      2. Uterine Descensus
      3. Severe cervical stenosis
4. Efficacy
   1. As effective as D&C for Endometrial Cancer
      1. Test Sensitivity: 99.6% (91% in premenopausal women)
      2. Test Specificity: >97%
   2. Insufficient sample (no glandular tissue) is common
   3. Misses most endometrial polyps and can miss focal Endometrial Hyperplasia
   4. References
      1. Dijkhuizen (2000) Cancer 89(8):1765-72
      2. Stovall (1989) Obstet Gynecol 73:405
5. Equipment: General Materials
   1. Sterile gloves
   2. Povidone-iodine solution (betadine)
   3. Benzocaine (Hurricane spray) or Lidocaine 2% jelly
   4. Sterile Gauze (4x4) for betadine application
6. Equipment: Sterile Uterine Pack (may use for IUD also)
   1. Sterile vaginal speculum
   2. Sterile Uterine sound
   3. Sterile scissors
   4. Sterile Ring forceps
   5. Sterile Cervical tenaculum
7. Equipment: Biopsy Materials
   1. Endometrial suction catheter (e.g. Pipelle)
   2. Labeled formalin container
   3. Sterile cervical dilator available if needed
8. Technique
   1. Non-sterile bimanual exam and speculum placement
      1. Determine Uterine Size and position
      2. Insert speculum
      3. Change to sterile gloves
      4. Apply topical anesthetic
   2. Apply topical antiseptic solution (povidone-iodine)
      1. Apply povidone-iodine to gauze or cotton balls
      2. Apply to Cervix and vagina with ring forceps
   3. Pain control
      1. Naproxen sodium 550 mg PO one hour before biopsy
      2. Lidocaine 2% solution 5 ml infused into Uterus
         1. Use 18 gauge angiocatheter sheath
         2. Leave angiocatheter in place for 3 minutes
      3. References
         1. Dogan (2004) Obstet Gynecol 103:347-51
   4. Apply tenaculum to 12:00 at anterior cervical lip
      1. Close very slowly when applying to minimize pain
   5. Insert uterine sound to determine uterine depth
      1. Normal depth: 6 to 8 cm
   6. Obtain endometrial sample (consider 2-3 samples)
      1. Insert suction catheter via cervical os to fundus
      2. Withdraw internal piston
      3. Move catheter tip in and out while twisting
         1. Do not remove catheter from Uterus (suction lost)
         2. Twist catheter to cover 360 degrees
         3. Make at least 4 in and out cycles per sample
      4. Withdraw catheter when filled with tissue
   7. Store sample in formalin
      1. Hold catheter over formalin container
      2. Reinsert internal piston to deposit sample in cup
9. Management: Stenotic cervical os
   1. Cytotec 200 mcg orally 6 hours before biopsy
10. Interpretation
    1. See Endometrial Biopsy Interpretation
11. References
    1. Apgar in Pfenninger (1994) Procedures 563-70
    2. Shelly (1997) Am Fam Physician 55(5): 1731-6
    3. Zuber (2001) Am Fam Physician 63(6): 1131-35