1. Endometrial Biopsy Oguchi Andrew Nwosu, MD, FAAFP Assistant Professor Emory Family Medicine

2. 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

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

4. Conditions Possibly Prohibiting Endometrial Biopsy Morbid obesity Severe pelvic relaxation with uterine descensus Severe cervical stenosis

5. 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

6. 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)

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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.

14. 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

15. Video http://www.youtube.com/watch?v=SchZAuGI 22s http://www.youtube.com/watch?v=SchZAuGI 22s

16. 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.

17. IUD Insertion

18. 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

19. Contraindications cont. Acute Liver disease or carcinoma * Breast cancer * Jaundice * Copper allergy ~ Wilson’s disease ~ * Mirena ~ Paraguard

20. 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

21. Mirena and Paragard IUD’s

22. Videos and Animations http://www.brooksidepress.org/Products/OBG YN_Skills_Lab/videos/IUD_Insertion_Video.ht m http://www.brooksidepress.org/Products/OBG YN_Skills_Lab/videos/IUD_Insertion_Video.ht m

23. 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)

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

25. Practice Makes Perfect