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Endometrial Biopsy
THOMAS J. ZUBER, M.D.

info Am Fam Physician. 2001;63(6):1131-1135

local_library A more recent article on endometrial biopsy is available.
(https://www.aafp.org/afp/2020/0501/p551.html)

“Office Procedures” forms on endometrial biopsy are provided on page 1139.

(afp20010315p1139.pdf)

share See patient information handout on endometrial biopsy

(https://www.aafp.org/afp/2001/0315/p1137.html).

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 (Tables 1 and 2). 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.

TABLE 1
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

Follow-up of previously diagnosed endometrial hyperplasia

Evaluation of uterine response to hormone therapy

Evaluation of patient with one year of amenorrhea

Evaluation of infertility

Abnormal Papanicolaou smear with atypical cells favoring endometrial origin

TABLE 2

Contraindications and Relative Contraindications for Endometrial Biopsy

Contraindications

Pregnancy

Acute pelvic inflammatory disease

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

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.

Methods and 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 (Hurricaine) 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 × 4 gauze (to wipe off gloves or equipment)

Sterile scissors (if the physician 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 physician is sterile-gloved and has placed the speculum, the nurse can spray the
benzocaine spray onto the cervix for 5 seconds, avoiding contamination of the sterile speculum
with the extended spray nozzle.

Procedure Description

1. The patient is placed in the lithotomy position and bimanual examination is performed (with
nonsterile gloves) to determine the uterine size and position, and whether marked
uterocervical angulation exists. Still wearing the nonsterile gloves, the physician can pick up
the sterile speculum from the sterile tray and place it in the patient's vagina. Avoid
contaminating the sterile instruments on the tray. Once the cervix is centered in the
speculum, the cervix can be anesthetized by spraying 20 percent benzocaine spray for 5
seconds and then cleansing it with povidone-iodine solution.

2. Alternately, the physician can apply sterile gloves, and insert the sterile speculum into the
patient's vagina. The physician should minimize contact of the sterile gloves with the
nonsterile vulvar tissues. The cervix is centered in the speculum and cleansed with povidone-
iodine solution. The gloves can be 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 sterile speculum with the extended spray nozzle.

3. The cervix is gently probed with the uterine sound. The cervix often is too mobile to allow for
passage of the sound but can be stabilized with the tenaculum. The tenaculum is placed on
the anterior lip of the cervix, grabbing enough tissue that the cervix will not 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 teeth in the
horizontal plane.

4. Pull outward on the tenaculum gently, straightening the uterocervical angle to reduce the
chance of posterior perforation. Attempt to insert the uterine sound to the fundus.
Occasionally, steady, moderate pressure is required to insert the sound through the closed
internal cervical os.
 5. 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.

6. The endometrial biopsy catheter tip is inserted into the cervix, 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 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.

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 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.

8. 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.

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.

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 authors 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 physicians will treat complex hyperplasia with or without atypia
with hormonal therapy (medroxyprogesterone, 10 to 20 mg daily for up to three months).
Most physicians 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.

Procedure Pitfalls/Complications

The Catheter Won't 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 authors recommend considering antibiotics in post-menopausal women at
risk for endocarditis. The risk for infection appears to be small, but some physicians
recommend tetracycline, 500 mg twice daily, for four days following the procedure.
The Pathologist Reports That the Specimens Have Insufficient Sample for Diagnosis. Some
physicians 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. 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 physician 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.

Physician Training

Endometrial biopsy is a fairly easy technique to learn. Physicians are often comfortable performing
the procedure unassisted after two to five precepted procedures. Physicians 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 physicians wanting intensive training.

This article is adapted with permission from Zuber TJ. Office procedures. Baltimore: Lippincott Williams &
Wilkins, 1999.

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