Endometrial Biopsy

Oguchi Andrew Nwosu, MD, FAAFP

Assistant Professor

Emory Family Medicine

Indications Abnormal uterine bleeding:

postmenopausal bleeding, malignancy/hyperplasia, ovulation/anovulation, HRT

Evaluation of patient with one year of presumed menopausal amenorrhea

Assessment of enlarged utereus (combined with US and neg HCG)

Monitoring adjuvant hormonal tx (tamoxifen)

Evaluation of infertility

Abnormal Pap smear with atypical cells favoring endometrial origin (AGUS)

Follow-up of previously diagnosed endometrial hyperplasia

Cancer screening (e.g., hereditary nonpolyposis colorectal cancer)

Inappropriately thick endometrial stripe found on US

Endometrial dating

Contraindications

Pregnancy Acute PID Clotting disorders (coagulopathy) Acute cervical or vaginal infections Cervical cancer

Conditions Possibly Prohibiting Endometrial Biopsy Morbid obesity Severe pelvic relaxation with uterine

descensus Severe cervical stenosis

Equipment

Non-sterile Tray (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 (Hurricaine) spray with the

extended application nozzle *

* Optional

Equipment

Sterile Tray for the Procedure 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)

Procedure

1. Patient in lithotomy position, bimanual exam to determine uterine size, position, uterocervical angulation.

2. Insert sterile speculum.3. Clean cervix with povidone-iodine solution.4. Sound the uterus. If needed, use tenaculum,

grasping the anterior lip of cervix, for counter-traction.

5. Pull outward with tenaculum to straighten the uterocervical angle.

6. Insert sound to the fundus, using steady moderate pressure. Usually measure 6-8 cm.

Procedure

7. May need cervical dilators if sound will not pass through internal os.

8. Insert sterile endometrial biopsy catheter tip into cervix to the fundus, or until resistance is felt, avoiding contamination from nearby tissues.

9. Fully withdraw the internal piston on the catheter, creating suction at the catheter tip.

10. Obtain tissue by moving with an in-and-out motion and using a 360-degree twisting motion. Allowing tip to exit endometrial cavity will lose suction.

FIGURE 1. Endometrial suction catheter. (A) The catheter tip is inserted into the uterus fundus or until resistance is felt. (B) Once the catheter is in the uterus cavity, the internal piston is fully withdrawn. (C) A 360-degree twisting motion is used as the catheter is moved between the uterus fundus and the internal os.

Procedure

11. Once the catheter fills with tissue, withdraw it, and place sample in the formalin container, by pushing piston back into the catheter tip. Make a second pass if necessary.

12. Remove tenaculum, apply pressure to any bleeding, then remove speculum.

Follow Up

Normal endometrial Proliferative (estrogen effect or preovulatory) Secretory (progesterone effect or postovulatory)

Atrophic endometrium Hormonal therapy

Cystic or simple hyperplasia w/o atypia Progress to cancer is < 5% Hormonal manipulation (medroxyprogesterone

[Provera], 10 mg daily for five days to three months)

Close follow-up w/ repeat EBx in 3-12 months

Follow-Up

Atypical complex hyperplasia Progresses to cancer in 30 to 45 % D&C to exclude endometrial cancer Consider hysterectomy for complex or high-

grade hyperplasia. Endometrial carcinoma

Referral to a gynecologic oncologist for definitive surgical therapy.

Pitfalls/Complications

The Catheter Won't Go Up into the Uterus Easily in Perimenopausal Patients. Insert an osmotic laminaria (seaweed) 3-mm dilator in the

patient morning of procedure.

Patients Report Cramping Associated with the Procedure. NSAIDS before procedure Topical anesthetic

The Procedure Should Not Be Performed in Pregnant Patients. R/O pregnancy in all women of childbearing age.

Pitfalls/Complications

Infection Occurs Following the Procedure. Adhere to strict sterile technique Antibiotics

The Pathologist Reports That the Specimens Have Insufficient Sample for Diagnosis. Use a second pass

The Tenaculum Causes Discomfort When Applied to the Cervix. Topical anesthetic

Video

http://www.youtube.com/watch?v=SchZAuGI22s

References

Zuber T. Endometrial Biopsy. American Family Physician. 2001;63:1131-1135

Baughan DM. Office endometrial aspiration biopsy. Fam Pract Res 1993;15:45-55.

IUD Insertion

Contraindications to IUD Insertion

Confirmed or suspected pregnancy History of Ectopic pregnancy Hx PID except subsequent preg. After Multiple sexual Partners Undiagnosed vaginal bleeding Uterine abnormality PP endometritis / septic abortion in last 3 mon Genital actinomycosis Immunodeficiency disorders Immunosuppressive therapy Known or suspected pelvic malignancy

Contraindications cont.

Acute Liver disease or carcinoma * Breast cancer * Jaundice * Copper allergy ~ Wilson’s disease ~

* Mirena ~ Paraguard

Equipment for IUD Insertion

Cervical tenaculum Long suture scissors Ring forceps Sterile and non sterile gloves Sterile IUD package and IUD Sterile tray Sterile vaginal speculum Uterine sound

Mirena and Paragard IUD’s

Videos and Animations

http://www.brooksidepress.org/Products/OBGYN_Skills_Lab/videos/IUD_Insertion_Video.htm

Adverse Effects or Complications from IUDs

Displaced threads Cramping Ectopic pregnancy Embedment or fragmentation of IUD Expulsion Infertility (I thought that was the purpose at least temporarily) Pelvic infections Septicemia during pregnancy Tubo-ovarian damage Uterine or cervical perforation Vaginal bleeding with or without anemia Vasovagal reaction (on insertion)

References

Johnson B. Insertion and Removal of Intrauterine Devices.2005;71:95-102

Practice Makes Perfect