Endometrial Biopsy

Aka: Endometrial Biopsy, Biopsy of Uterine Lining

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II. Indications

  1. Postmenopause
    1. Any uterine bleeding
    2. Incidental, asymptomatic thickened endometrium on Ultrasound does NOT automatically reflex to biopsy
      1. Consider Endometrial Cancer Risk Factors
  2. Premenopause
    1. Age >45 years old with Abnormal Uterine Bleeding
    2. Age <45 years old with Abnormal Uterine Bleeding
      1. Endometrial Cancer Risk Factors
      2. Persistent or heavy perimenopausal bleeding
      3. Refractory Anovulatory Dysfunctional Uterine Bleeding
      4. More than twelve months of Abnormal Uterine Bleeding
  3. Very high risk asymptomatic women
    1. See Endometrial Cancer Risk Factors
    2. Morbid Obesity
    3. Unopposed Estrogen
    4. Chronic Anovulation
    5. Tamoxifen use
    6. Endometrial Hyperplasia surveillance
    7. Hereditary Non-polyposis Colorectal Cancer (Lynch Syndrome)
      1. Lifetime risk of Endometrial Cancer 61%
      2. Screen with Endometrial Biopsy every 1-2 years starting at age 30-35 years
  4. Transvaginal Ultrasound with >4 mm endometrial thickness (endometrial stripe)
    1. Endometrial thickness <=4 mm has a 99% Negative Predictive Value for Endometrial Cancer
    2. (2018) Obstet Gynecol 131(5):e124-9 [PubMed]
  5. Abnormal Pap Smear with Atypical Glandular Cells (AGUS)
    1. Age over 35 years or Endometrial Cancer Risk Factors

III. 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

IV. Efficacy

  1. Endometrial Cancer Diagnosis (As effective as Dilation and Curettage)
    1. Test Sensitivity: 90 to 99% (91% in premenopausal women)
    2. Test Specificity: >97-100%
  2. Endometrial Hyperplasia Diagnosis
    1. Test Sensitivity for Endometrial Hyperplasia 82%
    2. Test Specificity approaches 100%
    3. Can miss focal Endometrial Hyperplasia
  3. Insufficient sample (no glandular tissue) is common
  4. References
    1. Dijkhuizen (2000) Cancer 89(8):1765-72 [PubMed]
    2. Stovall (1989) Obstet Gynecol 73:405 [PubMed]
    3. van Hanegem (2016) Eur J Obstet Gynecol Reprod Biol 197:147-55 [PubMed]

V. Equipment: General Materials

  1. Sterile gloves
  2. Povidone-Iodine solution (Betadine)
  3. Lidocaine gel 2% or 10% Lidocaine spray
  4. Sterile Gauze (4x4) for Betadine application

VI. 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

VII. Equipment: Biopsy Materials

  1. Endometrial suction catheter (e.g. Pipelle)
  2. Labeled formalin container
  3. Sterile cervical dilator available if needed

VIII. Technique

  1. Non-Sterile gloves for bimanual exam and speculum placement
    1. Determine Uterine Size and position
    2. Insert speculum
    3. Change to sterile gloves
    4. Apply Topical Anesthetic (see below)
  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. NaproxenSodium 550 mg orally 30-60 minutes before biopsy
    2. Topical Lidocaine
      1. Lidocaine gel 2% or 10% Lidocaine spray applied to Cervix (preferred)
        1. Apply 3 minutes before sounding
      2. Lidocaine 2% solution 5 ml infused into Uterus
        1. Use 18 gauge angiocatheter sheath
        2. Leave angiocatheter in place for 3 minutes
        3. Dogan (2004) Obstet Gynecol 103:347-51 [PubMed]
  4. Tenaculum use is optional
    1. Biopsy may often be performed without tenaculum
      1. Mobile Cervix or hyperangulated Cervix may require use of tenaculum
    2. Apply tenaculum to 12:00 at anterior cervical lip
    3. Close very slowly when applying to minimize pain
  5. Insert uterine sound to determine uterine depth
    1. Normal depth: 6 to 8 cm
    2. Too shallow a depth may indicate the sound has not passed through the internal cervical os
  6. Obtain endometrial sample (consider 2-3 samples)
    1. Insert suction catheter via cervical os to fundus
    2. Stabilize the catheter with one hand
    3. Withdraw internal piston to maximal point to apply suction within the catheter
    4. Move catheter tip in and out while twisting
      1. Do not remove catheter from Uterus (suction lost)
      2. Twist catheter between 2 fingers to cover 360 degrees
      3. Make at least 4 in and out cycles per sample
    5. Withdraw catheter when filled with tissue and expel into specimen cup
  7. Store sample in formalin
    1. Hold catheter over formalin container - with care not to touch formalin
    2. Reinsert internal piston to deposit sample in cup
  8. Remove the tenaculum
    1. Bleeding at tenaculum site
      1. Apply direct pressure
      2. Apply Silver Nitrate or Ferric Subsulfate (Monsel's Solution)

IX. Management: Stenotic cervical os

  1. Misoprostol (Cytotec) 200 mcg orally 6 hours before biopsy
    1. Routine use, however, is not recommended for women without cervical stenosis

X. Management: Post-Procedure Instructions

  1. Take NSAIDs for abdominal cramping
  2. Call or return indications
    1. Fever
    2. Persistent moderate to severe pelvic cramping
    3. Bleeding heavier than a menstrual period within the first 24-48 hours after Endometrial Biopsy

XI. Interpretation

  1. See Endometrial Biopsy Interpretation

XII. References

  1. Apgar in Pfenninger (1994) Procedures 563-70
  2. Shelly (1997) Am Fam Physician 55(5): 1731-6 [PubMed]
  3. Williams (2020) Am Fam Physician 101(9): 551-6 [PubMed]
  4. Zuber (2001) Am Fam Physician 63(6): 1131-35 [PubMed]

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