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Endometrial Biopsy THOMAS J

Endometrial Biopsy THOMAS J

OFFICE PROCEDURES

Endometrial THOMAS J. ZUBER, M.D., Saginaw Cooperative Hospital, Saginaw, Michigan

Endometrial biopsy is an office procedure that serves as a helpful tool in diagnos- ing various uterine abnormalities. The technique is fairly easy to learn and may be O A patient infor- performed without assistance. The biopsy is obtained through the use of an mation handout on endometrial catheter that is inserted through the into the uterine endometrial biopsy is provided on page 1137. cavity. Twirling the catheter while moving it in and out of the enhances uptake of uterine tissue, which is aspirated into the catheter and “Office Procedures” removed. Endometrial biopsy is useful in the work-up of abnormal uterine bleed- forms on endometrial ing, cancer screening, endometrial dating and evaluation. Contraindica- biopsy are provided on tions to the procedure include pregnancy, acute pelvic inflammatory disease, and page 1139. acute cervical or vaginal infections. Postoperative infection is rare but may be fur- ther prevented through the use of prophylactic antibiotic therapy. Intraoperative and postoperative cramping are frequent side effects. (Am Fam Physician 2001; 63:1131-5,1137-8,1139-41.)

This article is one in ndometrial biopsy is a safe and Formalin container (for endometrial a series adapted from accepted method for the evalua- sample) with the patient's name and the the Academy Collec- tion book “Office tion of abnormal or postmeno- date recorded on the label Procedures,” written pausal bleeding. The procedure is 20 percent benzocaine (Hurricaine) spray for family physicians often performed to exclude the with the extended application nozzle and designed to pro- Epresence of or its precur- vide the essential sors (Tables 1 and 2). Office endometrial suc- Sterile Tray for the Procedure details of commonly performed in-office tion catheters are easy to use, and several have Place the following items on a sterile drape procedures, and pub- been reported to have diagnostic accuracy covering the Mayo stand with the following lished by Lippincott that is equal or superior to the dilatation and items placed on top: Williams & Wilkins. curettage (D&C) procedure. Suction is gener- Sterile gloves ated by withdrawing an internal piston from Sterile vaginal within the catheter, and the tissue sample is Uterine sound obtained by twirling the catheter while mov- Sterile metal basin containing sterile ing it up and down within the uterine cavity. cotton balls soaked in povidone- Endometrial biopsy is a blind procedure iodine solution and should be considered part of the evalu- Endometrial suction catheter ation that could include imaging studies, Cervical such as or transvaginal ultra- Ring (for wiping the cervix with sonography. While a negative study is reas- the cotton balls) suring, further evaluation is warranted if a Sterile 4 4 gauze (to wipe off gloves or patient demonstrates continued abnormal equipment) bleeding. Sterile scissors (if the physician chooses to cut off the catheter tip to deliver the Methods and Materials endometrial sample into the formalin EQUIPMENT container) Nonsterile Tray for Examination Keep sterile cervical available, but for Uterine Position do not open the sterile packaging unless the Nonsterile gloves dilators are needed. Lubricating jelly Once the physician is sterile-gloved and has Absorbent pad to place beneath the placed the speculum, the nurse can spray the patient on the examination table benzocaine spray onto the cervix for 5 seconds,

MARCH 15, 2001 / VOLUME 63, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1131 wearing the nonsterile gloves, the physician TABLE 1 can pick up the sterile speculum from the Indications for Endometrial Biopsy sterile tray and place it in the patient's . Avoid contaminating the sterile instruments Abnormal uterine bleeding on the tray. Once the cervix is centered in the Postmenopausal bleeding speculum, the cervix can be anesthetized by Cancer screening (e.g., hereditary nonpolyposis spraying 20 percent benzocaine spray for colorectal cancer) 5 seconds and then cleansing it with povi- Detection of precancerous hyperplasia and atypia done-iodine solution. Endometrial dating 2. Alternately, the physician can apply ster- Follow-up of previously diagnosed endometrial ile gloves, and insert the sterile speculum into hyperplasia the patient's vagina. The physician should Evaluation of uterine response to hormone therapy minimize contact of the sterile gloves with Evaluation of patient with one year of amenorrhea the nonsterile vulvar tissues. The cervix is Evaluation of infertility centered in the speculum and cleansed with Abnormal Papanicolaou smear with atypical cells povidone-iodine solution. The gloves can be favoring endometrial origin washed with povidone-iodine solution if contaminated. The nurse can then spray the cervix with the 20 percent benzocaine spray for 5 seconds, avoiding contamination of the avoiding contamination of the sterile specu- sterile speculum with the extended spray lum with the extended spray nozzle. nozzle. 3. The cervix is gently probed with the uter- Procedure Description ine sound. The cervix often is too mobile to 1. The patient is placed in the lithotomy allow for passage of the sound but can be sta- position and bimanual examination is per- bilized with the tenaculum. The tenaculum is formed (with nonsterile gloves) to determine placed on the anterior lip of the cervix, grab- the uterine size and position, and whether bing enough tissue that the cervix will not marked uterocervical angulation exists. Still lacerate when traction is applied. The author prefers placement of the tenaculum in most cases, for increased safety, and grasps the anterior lip of the cervix with the tenaculum TABLE 2 teeth in the horizontal plane. Contraindications and Relative 4. Pull outward on the tenaculum gently, Contraindications for Endometrial Biopsy straightening the uterocervical angle to reduce the chance of posterior perforation. Contraindications Attempt to insert the uterine sound to the Pregnancy fundus. Occasionally, steady, moderate pres- Acute pelvic inflammatory disease Clotting disorders (coagulopathy) sure is required to insert the sound through Acute cervical or vaginal infections the closed internal cervical os. Cervical cancer 5. If the uterine sound will not pass Conditions possibly prohibiting endometrial through the internal os, consider placement biopsy of small Pratt uterine dilators. The smallest Morbid obesity size is inserted, followed by insertion of suc- Severe pelvic relaxation with uterine descensus cessively larger dilators until the sound passes Severe cervical stenosis easily to the fundus. The distance from the fundus to the external cervical os can be mea-

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sured by the gradations on the uterine sound and generally will be 6 to 8 cm. Endometrial biopsy may be complemented by various 6. The endometrial biopsy catheter tip is imaging studies, such as hysteroscopy or transvaginal inserted into the cervix, avoiding contamina- tion from the nearby tissues. The catheter tip ultrasonography. 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 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 (Figure 1). Make at least four up and down excursions to ensure that adequate tissue is in the catheter. A 7. 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 physicians prefer to Piston withdrawal make a second pass into the uterus with the catheter to optimize tissue sampling. If a sec- ond pass is to be made, the catheter should not be contaminated when being emptied of the first specimen. 8. The tenaculum is gently removed. Pres- B sure 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. Fundus Internal os Follow-Up . . Twirl sheath as catheter • Normal endometrial tissue may be is moved in and out (catheter filling) described as proliferative (estrogen effect or preovulatory) or secretory ( effect or postovulatory) endo- metrium. Hormone therapy can be offered to C patients with abnormal who ILLUSTRATION BY RENEE L. CANNON have normal endometrial tissue on biopsy. If FIGURE 1. Endometrial suction catheter. (A) The catheter tip is inserted into the uterus fundus or until resistance is felt. (B) Once the catheter the biopsy is normal but the patient contin- is in the uterus cavity, the internal piston is fully withdrawn. (C) A 360- ues to experience excessive vaginal bleeding, degree twisting motion is used as the catheter is moved between the further diagnostic work-up should occur. uterus fundus and the internal os.

MARCH 15, 2001 / VOLUME 63, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1133 • Atrophic endometrium generally yields tive cramping frequently accompany instru- scant or insufficient tissue for diagnosis. Hor- mentation of the uterine cavity. Preprocedure monal therapy may be considered for patients oral nonsteroidal anti-inflammatory medica- with atrophic endometrium. Persistent vagi- tions, such as ibuprofen (Motrin), can signif- nal bleeding should warrant further diagnos- icantly reduce the prostaglandin-induced tic work-up. cramping. Spraying the cervix with a topical • Cystic or simple hyperplasia progresses to anesthetic, such as 20 percent benzocaine, can cancer in less than 5 percent of patients. Most also help with discomfort. individuals with simple hyperplasia without • The Procedure Should Not Be Performed in any atypia can be managed with hormonal Pregnant Patients. Endometrial biopsy should manipulation (medroxyprogesterone [Pro- not be performed in the presence of a normal vera], 10 mg daily for five days to three or ectopic pregnancy. All patients with the months) or with close follow-up. Most potential for pregnancy should be considered authors recommend a follow-up endometrial for pregnancy testing prior to the perfor- biopsy after three to 12 months, regardless of mance of the procedure. the management strategy. • Infection Occurs Following the Procedure. • Atypical complex hyperplasia is a prema- Bacteremia, and acute bacterial endo- lignant lesion that progresses to cancer in carditis have been reported following endo- 30 to 45 percent of women. Some physicians metrial biopsy. Because postprocedure bac- will treat complex hyperplasia with or without teremia has been noted, some authors atypia with hormonal therapy (medroxyprog- recommend considering antibiotics in post- esterone, 10 to 20 mg daily for up to three menopausal women at risk for endocarditis. months). Most physicians recommend a D&C The risk for infection appears to be small, but procedure to exclude the presence of endome- some physicians recommend tetracycline, trial carcinoma and consider for 500 mg twice daily, for four days following the complex or high-grade hyperplasia. procedure. • Biopsy specimens that suggest the pres- • The Pathologist Reports That the Specimens ence of endometrial carcinoma (75 percent Have Insufficient Sample for Diagnosis.Some are adenocarcinoma) should prompt consid- physicians are less vigorous in obtaining spec- eration of referral to a gynecologic oncologist imens, and a single pass of the catheter may for definitive surgical therapy. not yield adequate tissue. A second pass can be made with the suction catheter if it is not con- Procedure Pitfalls/Complications taminated when it is emptied after the first • The Catheter Won't Go Up into the Uterus pass. The second pass almost always prevents Easily in Perimenopausal Patients. The internal reporting an insufficient sample. cervical os may be very tight in peri- • The Tenaculum Causes Discomfort When menopausal and menopausal patients. Be- Applied to the Cervix. Topical anesthesia can cause of the discomfort that can be created by reduce the discomfort from the tenaculum. instrumental cervical dilation, an alternative Placement of the tenaculum can make the in older patients is to insert an osmotic lami- procedure safer for the patient. The tenacu- naria (seaweed) 3-mm in the patient lum stabilizes the cervix and allows the that morning. Osmotic dilators cause gentle, physician to straighten the uterocervical slow opening of the cervix. The osmotic dila- angle. The tenaculum can reduce the chances tor is removed in the afternoon, and then the of posterior perforation when the plastic endometrial biopsy can be easily performed. catheter is inserted through the cervix and • Patients Report Cramping Associated with then through the thin-walled lower uterine the Procedure. Intraoperative and postopera- segment.

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Bayer SR, DeCherney AH. Clinical manifestations and Physician Training treatment of dysfunctional uterine bleeding. JAMA 1993;269:1823-8. Endometrial biopsy is a fairly easy technique Bremer CC. Endometrial biopsy. Female Patient 1992; to learn. Physicians are often comfortable per- 17:15-28. forming the procedure unassisted after two to Grimes DA. Diagnostic : a reap- five precepted procedures. Physicians who per- praisal. Am J Obstet Gynecol 1982;142:1-6. form other gynecologic procedures find that Kaunitz AM. Endometrial sampling in menopausal endometrial biopsy is a natural addition to patients. Menopausal Med 1993;1:5-8. their practice. The American Academy of Fam- Kaunitz AM, Masciello A, Ostrowski M, Rovira EZ. Com- parison of endometrial biopsy with the endometrial Pipelle ily Physicians offers a comprehensive training and Vabra aspirator. J Reprod Med 1988; 33:427-31. course in endometrial biopsy for physicians Livengood CH, Land MR, Addison A. Endometrial biopsy, wanting intensive training. bacteremia, and endocarditis risk. Obstet Gynecol 1985;65:678-81. Mettlin C, Jones G, Averette H, Gusberg SB, Murphy This article is adapted with permission from Zuber TJ. GP. Defining and updating the American Cancer Soci- Office procedures. Baltimore: Lippincott Williams & ety Guidelines for the cancer-related check-up: Wilkins, 1999. prostate and endometrial cancers. CA Cancer J Clin 1993;43:42-6.

RESOURCES Nesse RE. Managing abnormal vaginal bleeding. Post- grad Med 1991;89:208;213-14. Baughan DM. Office endometrial aspiration biopsy. Fam Reagan MA, Isaacs JH. Office diagnosis of endometrial Pract Res 1993;15:45-55. carcinoma. Prim Care Cancer 1992;12:49-52.

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