esources Rfor Women’s Health Volume 1, Number 1, October 1997 Endometrial Sampling Technologies for the Office or Clinic Forrest C. Greenslade, Ph.D.; José David Ortiz Mariscal, M.D.; Marian Abernathy, MPH he health care gy for resolving some by a non-physician for most women. By con- provider working in pathologies or circumstances provider), increases accessi- trast, D&C requires an oper- T private practice has related to a woman’s health bility as well as acceptability ating room which increases a wide range of health care that can arise at different technologies from which to times during her life. Table 1: Comparison of Vacuum choose in diagnosing and Aspiration and Sharp Curettage (D&C) managing obstetrical and Endometrial sampling can for Endometrial Sampling gynecological problems. be performed to determine Access to a variety of tech- the potential causes of infer- Vacuum Aspiration Sharp Curettage nologies has the potential to tility, to evaluate abnormal help health care providers uterine bleeding, to diagnose Uses flexible plastic or Requires a sharp curette offer better, more appropri- endometrial cancer or hyper- metal cannulae ate reproductive health care; plasia, and to monitor the effects of hormone replace- Does not require cervical Mechanical dilation often however, it can also lead to performed the overuse of some costly ment therapy. dilation technologies, such as ultra- Anesthesia or analgesia Paracervical anesthesia or sound, that may only be Vacuum aspiration is a sim- optional, depending on parenteral analgesic often available from specialists or ple, safe technology that can patient’s need administered in hospital settings. Other be used for endometrial sam- technologies provide innov- pling, and that, in many More convenient for — ative applications that can cases, can be used as an patient and provider be utilized in a wide range of alternative to sharp curet- settings. For example there tage or dilation and curet- Lower rate of complications — tage (D&C), a surgical pro- (uterine hemorrhage, are many occasions when infection and perforation) endometrial biopsy is appro- cedure that requires facilities with operating rooms (Table priate or requested for either Approximately 1/10 the cost — diagnostic or sampling pur- 1). Using vacuum aspiration of D&C per procedure poses. An endometrial sam- as an alternative to D&C pling technique using vacu- offers advantages for both Specimens consist of strips Specimens fragmented um aspiration can be per- the patient and provider. A of tissue with little blood and mixed with blood formed in an office or simple vacuum aspiration proce- clinic setting. This publica- dure, performed as an ambu- Office or outpatient Usually needs operating procedure room tion focuses on endometrial latory procedure in an office sampling: a useful technolo- or primary clinic (potentially Ipas Resources for Women’s Health 1 the cost of care; furthermore, um aspirator. By the early Suarez et al., 1983; Marik used to monitor the effect of the woman usually receives 90s, vacuum aspiration had and Tatarun, 1984; Hulka, hormone replacement thera- general anesthesia, increas- become the standard tech- 1988), so that Asherman’s py (Kaunitz, 1995). ing both her risk and recov- nology for endometrial biop- syndrome (associated with ery time. sy in the United States intrauterine adhesions and Vacuum Sources although sharp curettage is traumatic amenorrhea) may Endometrial sampling Technologies still used (Hulka, 1991). be less likely following vacu- devices achieve suction in Report um aspiration (Grimes, one of three ways: a vacuum Endometrial sampling Safety 1982). syringe, an internal piston, devices employing vacuum The safety advantage of vac- or a vacuum pump (Table aspiration provide in-office, uum aspiration over sharp Effectiveness 2). The Ipas MVA syringe diagnostic and monitoring curettage is supported by Histologic analyses of features a locking valve services minimizing the need research on vacuum aspira- endometrial tissue provide which allows the provider to for procedures requiring tion for a variety of indica- health care providers with establish a vacuum before D&C. tions. This body of research important information con- beginning the aspiration spans 30 years, encompasses cerning adenocarcinoma, procedure. Internal piston The use of vacuum aspira- over 80 studies, and involves atypical hyperplasia, polyps, devices generate suction that tion for endometrial biopsy more than 500,000 patients submucosal myomas, chron- draws a column of tissue into has been well established (Greenslade et al., 1993). ic inflammation, and proges- the tube when the piston is since Grimes’ 1982 analysis Vacuum aspiration removes tational effect in anovulatory withdrawn. Both mecha- of 13,598 sharp curettage less of the basal layer of the cycles (Baughan, 1993). nisms may be manual or procedures and 5,851 proce- endometrium than sharp Aspiration endometrial sam- electrical and are reusable. dures using the Vabra vacu- curettage (Hale et al., 1976; pling devices can also be Table 2: Endometrial Sampling Devices for the Office or Clinic Vacuum Source Locking-valve Syringe Internal Piston Electric or Mechanical Pump Characteristics Flexible cannulae, reusable Entire device is disposable Cannulae and collection of Use or disposable; reusable chamber disposable syringe Sampling Plastic (2-7mm) Cannulae Plastic (2-3mm) Plastic or stainless steel (2-7mm) (external diameter) 60 cc syringe collects large, Slim flexible device Sample chamber collects Endometrial diagnostically adequate sam- collects small but specimen; compares favor- Samples ple with a high ratio of diagnostically ably with those obtained by endometrial tissue to blood adequate sample diagnostic D&C clot. Ipas Gynecologic Aspiration Examples Pipelle, Z-Sampler, Tis-U-Trap, Vabra Aspirator, Kits with Cannulae & Syringe Gynosampler, Pipet Masterson Endometrial Biopsy System Curette 2 Resources for Women’s Health Ipas Cannula better quality than sharp cancer (Suarez et al., 1983) Endometrial samples Ipas 4mm flexible plastic curettage samples, as there and, when performed with obtained with MVA are par- cannulae for endometrial were larger strips of tissue hysteroscopy, superior to ticularly valuable for biopsy have two whistlecut and a higher ratio of tissue sharp curettage (Goldrath research because large sam- apertures near the distal end. to blood clot in the speci- and Sherman, 1985; Suarez ples can be obtained to pre- Novak’s 2-4mm cannulae men, facilitating pathologic et al., 1983). pare endometrial cells for tis- and Randall’s 4mm cannula diagnosis (Hale et al., 1976; sue cultures. Examination of for endometrial biopsy are Suarez et al., 1983). Mateo Sanez et al. found cell cultures derived from reusable and made of stain- 92.2% of samples obtained such samples yields valuable less steel. These cannulae Furthermore, MVA was with MVA were adequate, as insights into various aspects attach to the syringe via found to be as good a diag- compared with 84.4% of of reproductive physiology, Luer-Loks. Internal piston nostic tool as sharp curettage samples obtained with including certain types of devices are plastic and usual- in detecting endometrial Novak’s cannula. infertility. ly 3mm in external diameter. Pump vacuum sources use stainless steel or plastic can- nulae ranging from 2-7mm What is MVA? in diameter. MVA is a simple yet effective vacuum aspiration technique. This innovative technology consists of a flexible plastic cannula that is connected to a Endometrial manual aspiration syringe with a locking valve to perform an endometrial Sampling biopsy or a uterine evacuation. MVA is a very effective method and safer with Ipas MVA than sharp curettage. With the MVA instruments, a qualified health care Instruments provider may perform a wide range of ambulatory surgical procedures A number of studies evaluat- using the capabilities already available in the office or treatment room. ing endometrial biopsy per- Thus, the patient is not forced to be admitted to a hospital and instead can formed with MVA demon- undergo a safe and effective procedure in a private setting. strate it to be an effective and safe technology for col- lecting endometrial samples MVA Instruments Characteristics (Hale et al., 1976; Ladipo, ◆ Manufactured with high quality standards. 1976; Suarez et al., 1983; Goldrath and Sherman, ◆ Easy to learn: Each instrument kit contains detailed and illustrated 1985; Mateo Sanez et al., instructions to facilitate learning the operative technique. 1994). ◆ High level of effectiveness, safety and patient acceptability. Tissue samples collected with MVA were consistently ◆ Of practical use in the medical office, clinic and hospital. adequate for histologic diag- nosis (Hale et al., 1976; ◆ May be used with local anesthesia (paracervical block) so that the Ladipo, 1976; Mateo Sanez patient avoids the risk of epidural or general anesthesia. et al., 1994). Hale found MVA superior to sharp ◆ Of great application in ambulatory surgery. curettage in sampling the cornual regions of the uterus. ◆ Portable, not electric. In Suarez’ study, 82% of MVA samples were adequate for diagnosis compared to Combining all these characteristics, MVA yields a significant benefit for both 76% of those obtained with the provider and the patient. sharp curettage. MVA sam- ples were judged to be of Ipas Resources for Women’s Health 3 Use of MVA for endometrial Contraindications biopsy requires little if any and Precautions What are the pain control medication.