Presentation on theme: "Lianne Beck, MD Assistant Professor Emory Family Medicine"— Presentation transcript:
1Lianne Beck, MD Assistant Professor Emory Family Medicine Endometrial BiopsyLianne Beck, MDAssistant ProfessorEmory Family Medicine
2IndicationsAbnormal uterine bleeding: postmenopausal bleeding, malignancy/hyperplasia, ovulation/anovulation, HRTEvaluation of patient with one year of presumed menopausal amenorrheaAssessment of enlarged utereus (combined with US and neg HCG)Monitoring adjuvant hormonal tx (tamoxifen)Evaluation of infertilityAbnormal Pap smear with atypical cells favoring endometrial origin (AGUS)Follow-up of previously diagnosed endometrial hyperplasiaCancer screening (e.g., hereditary nonpolyposis colorectal cancer)Inappropriately thick endometrial stripe found on USEndometrial dating
3Contraindications Pregnancy Acute PID Clotting disorders (coagulopathy)Acute cervical or vaginal infectionsCervical cancer
5Equipment Non-sterile Tray (Examination for Uterine Position) Nonsterile glovesLubricating jellyAbsorbent pad to place beneath the patient on the examination tableFormalin container (for endometrial sample) with the patient's name and the date recorded on the label20 percent benzocaine (Hurricaine) spray with the extended application nozzle ** Optional
6Equipment Sterile Tray for the Procedure Sterile gloves Sterile vaginal speculumUterine soundSterile metal basin containing sterile cotton balls soaked in povidone-iodine solutionEndometrial suction catheterCervical tenaculumRing forceps (for wiping the cervix with the cotton balls)Sterile 4 x 4 gauze (to wipe off gloves or equipment)
7ProcedurePatient in lithotomy position, bimanual exam to determine uterine size, position, uterocervical angulation.Insert sterile speculum.Clean cervix with povidone-iodine solution.Sound the uterus. If needed, use tenaculum, grasping the anterior lip of cervix, for counter-traction.Pull outward with tenaculum to straighten the uterocervical angle.Insert sound to the fundus, using steady moderate pressure. Usually measure 6-8 cm.
8ProcedureMay need cervical dilators if sound will not pass through internal os.Insert sterile endometrial biopsy catheter tip into cervix to the fundus, or until resistance is felt, avoiding contamination from nearby tissues.Fully withdraw the internal piston on the catheter, creating suction at the catheter tip.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.
9FIGURE 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.
10ProcedureOnce 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.Remove tenaculum, apply pressure to any bleeding, then remove speculum.
11Follow Up Normal endometrial Atrophic endometrium Proliferative (estrogen effect or preovulatory)Secretory (progesterone effect or postovulatory)Atrophic endometriumHormonal therapyCystic or simple hyperplasia w/o atypiaProgress 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
12Follow-Up Atypical complex hyperplasia Endometrial carcinoma Progresses to cancer in 30 to 45 %D&C to exclude endometrial cancerConsider hysterectomy for complex or high-grade hyperplasia.Endometrial carcinomaReferral to a gynecologic oncologist for definitive surgical therapy.
13Pitfalls/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 procedureTopical anestheticThe Procedure Should Not Be Performed in Pregnant Patients.R/O pregnancy in all women of childbearing age.
14Pitfalls/Complications Infection Occurs Following the Procedure.Adhere to strict sterile techniqueAntibioticsThe Pathologist Reports That the Specimens Have Insufficient Sample for Diagnosis.Use a second passThe Tenaculum Causes Discomfort When Applied to the Cervix.Topical anesthetic
15ReferencesZuber T. Endometrial Biopsy. American Family Physician. 2001;63:Baughan DM. Office endometrial aspiration biopsy. Fam Pract Res 1993;15:45-55.