OFFICE PROCEDURES

Endometrial Biopsy
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 suction catheter that is inserted through the cervix into the uterine endometrial biopsy is
provided on page 1137.
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 “Office Procedures”
removed. Endometrial biopsy is useful in the work-up of abnormal uterine bleed- forms on endometrial
ing, cancer screening, endometrial dating and infertility 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.)

E
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- presence of endometrial cancer 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 speculum
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 tenaculum
such as hysteroscopy or transvaginal ultra- Ring forceps (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 dilators 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 vagina.
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-

1132 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 6 / MARCH 15, 2001
 Endometrial Biopsy

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 Uterus
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
Follow-Up os
. . Twirl sheath as catheter
ILLUSTRATION BY RENEE L. CANNON

• Normal endometrial tissue may be is moved in and out

(catheter filling)
described as proliferative (estrogen effect or
preovulatory) endometrium or secretory
(progesterone effect or postovulatory) endo-
metrium. Hormone therapy can be offered to C
patients with abnormal vaginal bleeding who
FIGURE 1. Endometrial suction catheter. (A) The catheter tip is inserted
have normal endometrial tissue on biopsy. If
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, sepsis 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 hysterectomy 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 dilator 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.

1134 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 6 / MARCH 15, 2001
 Endometrial Biopsy

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 dilation and curettage: 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.

MARCH 15, 2001 / VOLUME 63, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1135