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Endometrial Biopsy Description Reasons For Endometrial Biopsy Endometrial Biopsy Risk Factors Endometrial Biopsy Procedure Description Endometrial Biopsy Expected Outcome Endometrial Biopsy Complications Endometrial Biopsy Post Procedure Care Medication Activity Recommendations & Restrictions Diet & Nutrition Notify Your Health Care Provider
ENDOMETRIAL BIOPSY DESCRIPTION
An endometrial biopsy (also known as an uterine biopsy) is a diagnostic procedure that involves removal of tissue from the endometrium, the inner lining of the uterus. The sample is looked at under a microscope for abnormal cells. An endometrial biopsy helps your health care provider to find any problems in the endometrium. It also lets your health care provider to check to see if your body's hormone levels that affect the endometrium are in balance.
The lining of the uterus changes throughout a woman's menstrual cycle. Early in the menstrual cycle, the lining grown thicker until a mature egg is released from an ovary during ovulation. If the egg is not fertilized by a sperm, the endometrial lining is shed during normal menstrual bleeding.
REASONS FOR ENDOMETRIAL BIOPSY PROCEDURE
INDICATIONS FOR ENDOMETRIAL BIOPSY
Abnormal uterine bleeding. Postmenopausal bleeding. Cancer screening (e.g., hereditary nonpolyposis colorectal cancer) Detection of precancerous hyperplasia and atypia. Endometrial dating. Followup of previously diagnosed endometrial hyperplasia. Evaluation of uterine respons to hormone therapy. Evaluation of patient with one year of amenorrhea. Evaluation of infertility. Abnormal Papanicolaou (Pap) Smear with atypical cells favoring endometrial origin.
CONTRAINDICATIONS & RELATIVE CONTRAINDICATIONS FOR ENDOMETRIAL BIOPSY
- Acute pelvic inflammatory disease (PID).
- Clotting disorders (coagulopathy).
- Acute cervical or vaginal infections.
- Cervical cancer.
Conditions possibly preventing endometrial biopsy:
- Morbid obesity.
- Severe pelvic relaxation with uterine descensus.
- Severe cervical stenosis.
Investigation of fertility issues in a patient who has been unable to become pregnant. This procedure will help your health care provider to see whether the lining of the uterus (endometrium) is going through normal menstrual cycle changes and whether or not it can support a pregnancy. Hormonal levels may be analyzed.
Investigation of bleeding between menstrual periods, heavy, prolonged and/or irregular uterine bleeding. An endometrial biopsy may be done to find the cause of abnormal uterine bleeding, to check for overgrowth of the lining (endometrial hyperplasia).
Check for cancer. An endometrial biopsy is done to help determine the cause of a Pap test result showing glandular cell changes that may lead to cancer in women older than 35. Glandular cells are a type of cell found in the cervix and the endometrium.
An endometrial biopsy is sometimes done at the same time as another test, called hysteroscopy, which allows your health care provider to look through a small lighted tube at the lining of the uterus.
Laboratory examination of the removed tissue aids in diagnosis. If appropriate, the procedure is performed during the last 2 weeks of the patient's menstrual cycle. This is the best time to identify possible hormonal problems and to determine if ovulation is occurring.
ENDOMETRIAL BIOPSY RISK FACTORS
None expected. There are very few risks with endometrial biopsy. The leading risk is pain, followed by possible infection, bleeding and rarely perforation of the uterus.
DESCRIPTION OF ENDOMETRIAL BIOPSY PROCEDURE
Endometrial biopsy is an office procedure that serves as a helpful tool in diagnosing various uterine abnormalities. The technique is fairly easy to learn and may be performed without assistance. The biopsy is obtained through the use of an endometrial suction catheter that is inserted through the cervix into the uterine cavity. Twirling the catheter while moving it in and out of the uterine cavity enhances uptake of uterine tissue, which is aspirated into the catheter and removed. Endometrial biopsy is useful in the work-up of abnormal uterine bleeding, cancer screening, endometrial dating and infertility evaluation. Contraindications to the procedure include pregnancy, acute pelvic inflammatory disease, and acute cervical or vaginal infections. Postoperative infection is rare but may be further prevented through the use of prophylactic antibiotic therapy. Intraoperative and postoperative cramping are frequent side effects.
Endometrial biopsy is a safe and accepted method for the evaluation of abnormal or postmenopausal bleeding. The procedure is often performed to exclude the presence of endometrial cancer or its precursors. Office endometrial suction catheters are easy to use, and several have been reported to have diagnostic accuracy that is equal or superior to the dilatation and curettage (D & C) procedure. Suction is generated by withdrawing an internal piston from within the catheter, and the tissue sample is obtained by twirling the catheter while moving it up and down within the uterine cavity. Endometrial biopsy is a blind procedure and should be considered part of the evaluation that could include imaging studies, such as hysteroscopy or transvaginal ultrasonography. While a negative study is reassuring, further evaluation is warranted if a patient demonstrates continued abnormal bleeding.
PREPARING FOR THE PROCEDURE
Let your health care provider know if you:
- Are or might be pregnant. An endometrial biopsy is not done during pregnancy.
- Are taking any medications.
- Are allergic to any medications.
- Have ever had bleeding problems or take blood thinners, such as aspirin or warfarin (Coumadin).
- Have been treated for a vaginal, cervical, or pelvic infection.
- Have any heart or lung problems.
Do not douche, use tampons, or use vaginal medications for 24 hours before the biopsy. You will empty your bladder just before your biopsy.
You may want to take a pain reliever, such as ibuprofen (Advil or Motrin), 30 to 60 minutes before the biopsy. This can help decrease any cramping pain that can be caused by the biopsy.
You will be asked to sign a consent form that says you understand the risks of an endometrial biopsy and agree to have the test done. Talk with your health care provider about any concerns you have regarding the procedure, its risks, how it will be done, or what the results may mean.
If you are having a dilation and curettage (D&C) and will go to sleep (general anesthesia) for the test, do not eat or drink anything for 8 hours before the test. If you are taking any medications. Ask your health care provider what medications you can take the day of the test.
METHODS & MATERIALS - EQUIPMENT
Nonsterile Tray for Examination for Uterine Position
- Nonsterile gloves.
- Lubricating jelly.
- Absorbent pad to place beneath the patient on the examination table.
- Formalin container (for endometrial sample) with the patient's name and the date recorded on the label.
- 20 percent benzocaine spray with the extended application nozzle.
Sterile Tray for the Procedure
Place the following items on a sterile drape covering the Mayo stand with the following items placed on top:
- Sterile gloves.
- Sterile vaginal speculum.
- Uterine sound.
- Sterile metal basin containing sterile cotton balls soaked in povidone-iodine solution.
- Endometrial suction catheter.
- Cervical tenaculum.
- Ring forceps (for wiping the cervix with the cotton balls).
- Sterile 4 X 4 gauze (to wipe off gloves or equipment).
- Sterile scissors (if the practitioner chooses to cut off the catheter tip to deliver the endometrial sample into the formalin container).
- Keep sterile cervical dilators available, but do not open the sterile packaging unless the dilators are needed.
Once the practitioner is sterile-gloved and has placed the speculum, the assistant can spray the benzocaine spray onto the cervix for 5 seconds, avoiding contamination of the sterile speculum with the extended spray nozzle.
PERFORMING THE PROCEDURE
The procedure is Usually performed in the health care provider's office with little or no anesthesia necessary by a practitioner trained to do the procedure. The sample will be looked at by a pathologist.
You will need to take off your clothes below the waist. You will be given a covering to drape around your waist. You will lie on your back (lithotomy position) on an examination table with your feet up in stirrups. A bimanual examination is performed by your practitoner (with non sterile gloves) to determine the uterine size and position, and whether marked uterocervical angulation exists..
Still wearing the nonsterile gloves (or alternately the practtioner can apply sterile gloves), the practitioner can pick up the sterile speculum from the sterile tray and place it in the patient's vagina while avoiding contaminating the sterile instruments on the tray. The practitioner should minimize contact of the sterile gloves with the nonsterile vulvar tissues. A speculum is an instrument with smooth, curved blades resembling a "duck bill". It is is inserted into the vagina to bring the cervix into view. The speculum gently spreads apart the vaginal walls so your health care provider can see inside the vagina and the cervix. Once the cervix is centered in the speculum, the cervix can be anesthetized by spraying 20 percent benzocaine spray for 5 seconds, avoiding contamination of the sterile speculum with the extended spray nozzle. The cervix is washed, cleaned with a special solution (such as a povidone-iodine solution).
The cervix is gently probed with the uterine sound. The cervix often is too mobile to allow for passage of the sound but may need to be stabilized. In some cases, it is necessar to use a clamp called a tenaculum (a hook-like instrument that holds andn helps stabilize the cervix). The tenaculum is placed on the anterior lip of the cervix, grabbing enough tissue so that the cervix will not lacerate when traction is applied. The practitioner may prefer placement of the tenaculum in most cases, for increased safety, grasping the anterior lip of the cervix with the tenaculum teeth in the horizontal plane. The tenaculum is pulled outward gently, straightening the uterocervical angle to reduce the chance of posterior perforation.
Insertion of the uterine sound is attempted to the fundus. Occasionally, steady moderate pressure is required to insert the sound through the closed internal cervical os. If the uterine sound will not pass through the internal os, consider placement of small Pratt uterine dilators. The smallest size is inserted, followed by insertion of successively larger dilators until the sound passes easily to the fundus. The distance from the fundus to the external cervical os can be measured by the gradations on the uterine sound and generally will be 6 to 8 cm.
A tool (endometrial biopsy catheter tip) is used to collect the sample. It is guided through the cervix and inserted into the uterus, avoiding contamination from the nearby tissues. The catheter tip is then inserted into the uterine fundus or until resistance is felt. Once the catheter is in the uterine cavity, the internal piston on the catheter is fully withdrawn, creating suction at the catheter tip. The tool may be moved up and down to collect the sample.The catheter tip is moved with an in-and-out motion, but the tip does not exit the endometrial cavity through the cervix, which maintains the vacuum effect. Use a 360-degree twisting motion to move the catheter between the uterine fundus and the internal cervical os). Make at least four up and down excursions to ensure that adequate tissue is in the catheter.
The endometrial biopsy catheter tip is guided through the cervix and inserted into the uterus up to the uterine fundus (top of the uterus) or until resistence is felt.
Once the catheter is inside the uterine cavity, the internal piston on the catheter is fully withdrawn, creating suction at the catheter tip.
Tissue is obtained by using a twisting 360° motion of the catheter tip as it is moved in a back and forth motion between the uterine fundus and the internal cervical os.
Once the catheter fills with tissue, it is withdrawn, and the sample is placed in the formalin container. To remove the sample from the endometrial catheter, the piston can be gently reinserted, forcing the tissue out of the catheter tip. Some practitioners prefer to make a second pass into the uterus with the catheter to optimize tissue sampling. If a second pass is to be made, the catheter should not be contaminated when being emptied of the first specimen.
The tenaculum is gently removed. Pressure can be applied with cotton swabs if the tenaculum sites bleed following removal of the tenaculum. Excess blood and povidone-iodine solution are wiped from the vagina, and the vaginal speculum is removed.
Most women have some cramping during the biopsy. An endometrial biopsy usually takes 5 to 15 minutes to perform.
There are several methods of obtaining an endometrial biopsy. Your health care provider may use one of these methods:
A small, spoon-shaped instrument (or other biopsy instrument) is inserted through the cervix into the uterus. It is gently scraped against the inner lining of the uterus to gather tissue. A curette is used for a dilation and curettage (D&C). A D & C may be done to control heavy uterine bleeding (hemorrhage) or to help find the cause of bleeding. This is done with general or regional anesthesia.
An alternate method involves obtaining the tissue sample with a suction instrument. The suction instrument may be a soft, straw-like device that suctions a small sample of the lining from the uterus. This method is fast and is not very painful. An electronic suction device (Vabra aspiration) may be used. This method can be uncomfortable.
A spray of liquid (jet irrigation) to wash off some of the tissue that lines the uterus may be done. A brush may be used to remove some of the lining before the washing is done.
The instruments are removed. The surgery may cause slight pain, but it should be minor and temporary.
ENDOMETRIAL BIOPSY FOLLOW-UP
Normal endometrial tissue may be described as proliferative (estrogen effect or preovulatory) endometrium or secretory (progesterone effect or postovulatory) endometrium. Hormone therapy can be offered to patients with abnormal vaginal bleeding who have normal endometrial tissue on biopsy. If the biopsy is normal but the patient continues to experience excessive vaginal bleeding, further diagnostic work-up should occur.
Atrophic endometrium generally yields scant or insufficient tissue for diagnosis. Hormonal therapy may be considered for patients with atrophic endometrium. Persistent vaginal bleeding should warrant further diagnostic work-up.
Cystic or simple hyperplasia progresses to cancer in less than 5 percent of patients. Most individuals with simple hyperplasia without any atypia can be managed with hormonal manipulation (medroxyprogesterone [Provera], 10 mg daily for five days to three months) or with close follow-up. Most practitioners recommend a follow-up endometrial biopsy after three to 12 months, regardless of the management strategy.
Atypical complex hyperplasia is a premalignant lesion that progresses to cancer in 30 to 45 percent of women. Some practitioners will treat complex hyperplasia with or without atypia with hormonal therapy (medroxyprogesterone, 10 to 20 mg daily for up to three months). Most practitioners recommend a D & C procedure to exclude the presence of endometrial carcinoma and consider hysterectomy for complex or high-grade hyperplasia.
Biopsy specimens that suggest the presence of endometrial carcinoma (75 percent are adenocarcinoma) should prompt consideration of referral to a gynecologic oncologist for definitive surgical therapy.
WHAT TO EXPECT
If you have not had any pain medication, you may feel a sharp cramp as the tool is guided through the cervix. You may feel more cramping when the biopsy sample is collected. Most women find that the cramping feels like a really bad menstrual cramp.
Some women feel dizzy and sick to their stomachs. This is called a vasovagal reaction. This feeling will go away after the biopsy.
An endometrial biopsy usually causes some vaginal bleeding. You can use a pad for the bleeding or spotting.
If general anesthesia is used during a D&C, you will be asleep and feel nothing. After the test, you will feel sleepy for a few hours. You may be tired for a few days after the procedure. You may experience a mild sore throat if a tube, called an endotracheal tube or ET, was placed in your throat to help you breathe during the test. Using throat lozenges and gargling with warm salt water may help relieve your sore throat.
You will need to have someone drive you home after the procedure, especially if you have had any kind of anesthesia. Be sure to make arrangements for a ride prior to the procedure.
ENDOMETRIAL BIOPSY EXPECTED OUTCOME
Tissue obtained successfully without complications in virtually all cases. Allow about 1 week for recovery from the procedure. During this time, you should expect vaginal discharge.
Laboratory testing on the tissue can confirm ovulation has occurred and may identify other causes of infertility, such as infection.
Laboratory examination will generally determine if there are any abnormal cells found in the uterine lining.
Lab results may take several days to get back. A report will be sent to your health care provider.
ENDOMETRIAL BIOPSY RESULTS
No abnormal cells or cancer is found. For women who have menstrual cycles, the lining of the uterus is at the right stage for the time in the menstrual cycle when the biopsy was done.
A non-cancerous (benign) growth, called a polyp, is present.
Overgrowth of the lining of the uterus (endometrial hyperplasia) is present.
Cell changes that may lead to cancer are present.
For women who have menstrual cycles, the lining of the uterus is not at the right stage for the time in the menstrual cycle when the biopsy was done. More tests may be needed.
FACTORS THAT AFFECT THE TEST
Reasons you may not be able to have the endometrial biopsy or why the results may not be helpful include:
- If a vaginal or cervical infection is present. The infection could spread to the uterus if an endometrial biopsy is performed.
- If the endometrial biopsy sample is not large enough to see abnormal cells, another test may be needed.
- More of the uterine lining can be sampled during a D & C than during an endometrial biopsy. A hysteroscopy may be done with a D & C so that the health care provider can see the lining of your uterus. A hysteroscopy may also be done instead of a D & C.
- An endometrial biopsy is not done during pregnancy.
- An endometrial biopsy is not usually done during or after menopause unless a woman has abnormal vaginal bleeding. Some health care providers may do a biopsy before prescribing hormone replacement therapy (HRT).
MoonDragon's Womens Health Procedures Information: Dilation & Curettage (D&C)
MoonDragon's Womens Health Procedures Information: Hysteroscopy
MoonDragon's Womens Health Procedures Information: Pap Smear
MoonDragon's Womens Health Procedures Information: Pelvic Exam
MoonDragon's Womens Health Procedures Information: Uterine Abnormalities
MoonDragon's Womens Health Information: Uterine Cancer
MoonDragon's Womens Health Information: Uterine Dysfunctional Bleeding
MoonDragon's Womens Health Information: Uterine Bleeding, Post-Menopausal
ENDOMETRIAL BIOPSY POTENTIAL COMPLICATIONS
Excessive bleeding. Surgical-wound infection. Inadvertent injury to the uterus.
PROCEDURE COMPLICATIONS & PITFALLS
The catheter will not go up into the uterus easily in perimenopausal patients. The internal cervical os may be very tight in perimenopausal and menopausal patients. Because of the discomfort that can be created by instrumental cervical dilation, an alternative in older patients is to insert an osmotic laminaria (seaweed) 3-mm dilator in the patient that morning. Osmotic dilators cause gentle, slow opening of the cervix. The osmotic dilator is removed in the afternoon, and then the endometrial biopsy can be easily performed.
Patients report cramping associated with the procedure. Intraoperative and postoperative cramping frequently accompany instrumentation of the uterine cavity. Preprocedure oral nonsteroidal anti-inflammatory medications, such as ibuprofen (Motrin), can significantly reduce the prostaglandin-induced cramping. Spraying the cervix with a topical anesthetic, such as 20 percent benzocaine, can also help with discomfort.
The procedure should not be performed in pregnant patients. Endometrial biopsy should not be performed in the presence of a normal or ectopic pregnancy. All patients with the potential for pregnancy should be considered for pregnancy testing prior to the performance of the procedure.
Infection occurs following the procedure. Bacteremia, sepsis and acute bacterial endocarditis have been reported following endometrial biopsy. Because postprocedure bacteremia has been noted, some practitioners recommend considering antibiotics in post-menopausal women at risk for endocarditis. The risk for infection appears to be small, but some practitioners recommend tetracycline, 500 mg twice daily, for four days following the procedure.
The pathologist reports that the specimens have insufficient sample for diagnosis. Some practitioners are less vigorous in obtaining specimens, and a single pass of the catheter may not yield adequate tissue. A second pass can be made with the suction catheter if it is not contaminated when it is emptied after the first pass. If the catheter is contaminated during removal, a second sterile catheter may need to be inserted for a second tissue gathering. The second pass almost always prevents reporting an insufficient sample.
The tenaculum causes discomfort when applied to the cervix. Topical anesthesia can reduce the discomfort from the tenaculum. Placement of the tenaculum can make the procedure safer for the patient. The tenaculum stabilizes the cervix and allows the practitioner to straighten the uterocervical angle. The tenaculum can reduce the chances of posterior perforation when the plastic catheter is inserted through the cervix and then through the thin-walled lower uterine segment.
Practitioner training is inadequate. Endometrial biopsy is a fairly easy technique to learn. Practitioners are often comfortable performing the procedure unassisted after two to five precepted procedures. Practitioners who perform other gynecologic procedures find that endometrial biopsy is a natural addition to their practice. The American Academy of Family Physicians offers a comprehensive training course in endometrial biopsy for practitioners wanting intensive training.
ENDOMETRIAL BIOPSY POST PROCEDURE CARE
Bathe or shower as usual. Use mild, non-scented, non-perfumed soap. Wear sanitary pads for the rest of this menstrual period. Avoid tampons temporarily; they may lead to infection. Your menstrual flow may be heavier than usual. Wear cotton underpants and pantyhose with a cotton crotch. Avoid underwear made from nylon, polyester, silk or other non-ventilating materials. Do not douche unless it is prescribed for you.
Hormonal therapy, if a hormonal imbalance is confirmed. You may use non-prescription drugs, such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), for minor pain.
MoonDragon's Menopause Information: Hormone Replacement Therapy (HRT)
ACTIVITY RECOMMENDATIONS & RESTRICTIONS
Resume daily activities and work as soon as possible. You can usually do most of your activities in a few days. Do not lift anything heavy for a few days after the test. Do not douche or have sex for one week after the procedure.
DIET & NUTRITION
No special diet. However, you should follow a healthy, balanced nutritional program for a healthy immune system and to assist in a rapid recovery from your procedure.
MoonDragon's Nutrition Information: Adult Regular Diet
MoonDragon's Nutrition Information, Guidelines, Dietary Recommendations
NOTIFY YOUR HEALTH CARE PROVIDER
Vaginal discharge increases or begins to have an unpleasant odor. You experience pain that simple medication does not relieve quickly. Unusually heavy vaginal swelling or bleeding develops.
Zuber TJ. Office procedures. Baltimore: Lippincott Williams & Wilkins, 1999
Baughan DM. Office endometrial aspiration biopsy. Fam Pract Res. 1993;15:45-55.
Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA. 1993;269:1823-8.
Bremer CC. Endometrial biopsy. Female Patient. 1992;17:15-28.
Grimes DA. Diagnostic dilation and curettage: a reappraisal. Am J Obstet Gynecol. 1982;142:1-6.
Kaunitz AM. Endometrial sampling in menopausal patients. Menopausal Med. 1993;1:5-8.
Kaunitz AM, Masciello A, Ostrowski M, Rovira EZ. Comparison of endometrial biopsy with the endometrial Pipelle and Vabra aspirator. J Reprod Med. 1988;33:427-31.
Livengood CH, Land MR, Addison A. Endometrial biopsy, bacteremia, and endocarditis risk. Obstet Gynecol. 1985;65:678-81.
Mettlin C, Jones G, Averette H, Gusberg SB, Murphy GP. Defining and updating the American Cancer Society Guidelines for the cancer-related check-up: prostate and endometrial cancers. CA Cancer J Clin. 1993;43:42-6.
Nesse RE. Managing abnormal vaginal bleeding. Postgrad Med. 1991;89:208;213-14.
Reagan MA, Isaacs JH. Office diagnosis of endometrial carcinoma. Prim Care Cancer. 1992;12:49-52.
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