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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Gynecology and Urology > 35 – Endometrial Biopsy 35 Endometrial Biopsy Endometrial biopsy (EMB) is a safe and effective method for diagnosing various endometrial abnormalities. It provides a minimally invasive assessment of the endometrium that may be used as an alternative to dilatation and curettage or hysteroscopy. Modern suction catheters have made this outpatient technique easy to learn and perform. EMB is most commonly employed in the workup of abnormal uterine bleeding, but it can also be used for cancer screening, endometrial dating, and infertility evaluation. This technique provides part of a cost-effective diagnostic workup for abnormal uterine bleeding without reducing clinical accuracy. Catheter-type EMBs are safe. Uterine perforations are rare unless the device is forced. Postoperative infection is rare but may be prevented with the use of prophylactic antibiotic therapy such as doxycycline (100 mg) administered twice daily for 4 days after the procedure. The patient may also be premedicated with ibuprofen (600 to 800 mg) at least 1 hour before the procedure to decrease the cramping associated with the sampling. Bacterial endocarditis prophylaxis can be considered (see Appendix I). Intraoperative and postoperative cramping is a frequent side effects of the procedure. Some physicians prefer to apply a tenaculum and give slight countertraction toward the operator. Although a tenaculum helps stabilize the cervix, it also causes additional pain and bleeding. It may also be used to straighten a markedly anteverted or retroverted uterus and may make the procedure safer in this setting. If used, it should be applied to the anterior lip of the cervix with the teeth in a horizontal plane. Because of the stenosis of the cervical os that develops in low-estrogen states, it can be difficult to perform an EMB in postmenopausal women. Elderly women can have a laminaria (i.e., thin piece of dried, sterile seaweed) placed in the cervix in the morning and then return in the afternoon to have the swollen (now moistened) laminaria removed immediately before the procedure. A cervical dilator may also be used when the EMB catheter can not be passed through the internal os in postmenopausal women. Topical benzocaine solution (i.e., Hurricaine solution) may be applied to the cervix to decrease the pain from entry of the curette into the uterus. A cervical or pericervical block also may be used. For a cervical block, inject 1% to 2% lidocaine with epinephrine submucosally in the center of each cervical quadrant. P.248
Anesthesia may be applied at any time during the procedure. Some data suggest instilling 5 mL of 2% lidocaine into the uterine cavity before endometrial biopsies significantly decreases the pain of the EMB. INDICATIONS

  • Examination for dysfunctional uterine bleeding (to rule out endometrial hyperplasia or cancer)
  • Workup for glandular atypia or endometrial cells seen on the Papanicolaou (Pap) smear
  • Monitor unopposed estrogen therapy for the development of hyperplasia
  • Endometrial dating
  • Infertility evaluation

CONTRAINDICATIONS

  • Pregnancy or suspected pregnancy
  • Acute pelvic inflammatory disease
  • Acute cervical or vaginal infections
  • Uncooperative patient (relative contraindication)
  • Severe cervical stenosis (relative contraindication)

P.249
PROCEDURE Explain the procedure, and obtain informed consent. Perform a pelvic examination. Determine the size and position of the uterus. Apply povidone-iodine (Betadine) to the ectocervix and external os with a swab or cotton ball. Sound the uterus (normal depth is 6 to 9 cm).

(1) Apply povidone-iodine (Betadine) to the ectocervix and external os with a swab or cotton ball.

PITFALL: Check for masses or structural abnormalities, cervical stenosis, or signs of infection that may make the procedure more difficult or impossible. PITFALL: When inserting the sound, apply firm, steady forward pressure to pass through the tightly closed internal os of the upper cervix. Be prepared to immediately pull back after the internal os is penetrated, or the tip of the sound can be thrust forward against the upper uterus and perforate the opposing wall. Perforations also can occur through the thin lower uterine segment. Placement of a tenaculum and straightening of the uterocervical angle can help reduce perforation after the sound passes through the internal os. P.250
With the central piston fully inserted into the sheath (do not pull out), the endometrial sampler is inserted into the os until it reaches the fundus. Note the depth of insertion. Do not touch the end of the device that is to be inserted or allow it to touch the patient except at the os.

(2) With the central piston fully inserted into the sheath, the endometrial sampler is inserted into the os until it reaches the fundus.

PITFALL: If strong resistance is encountered, consider repeat sounding the uterus. If still unable to enter the endometrial cavity with the EMB catheter, abort the procedure. Forcing the catheter may result in uterine perforation. PITFALL: If the catheter bends excessively, apply a small amount of torque to the catheter. This causes it to flex less. Holding the sheath steady, pull back on the piston until it stops. This creates negative pressure inside the curette. Leave the piston fully retracted.

(3) Holding the sheath steady, pull back on the piston until it stops.

P.251
Roll or twirl the sheath laterally between the thumb and fingers while simultaneously moving the sheath tip back and forth between the fundus and internal os. Tissue should move into the sheath as the operation progresses. Complete the maneuver three or four times to obtain the sample.

(4) Roll or twist the sheath laterally between the thumb and fingers while simultaneously moving the sheath tip back and forth between the fundus and internal os.

PITFALL: Do not allow the hole in the tip to emerge from the cervix, or all of the suction will be lost. P.252
Remove the sampling device, and cut off the distal tip (Figure 5A). Slowly push the piston completely into the sheath to expel the sample into the fixative (Figure 5B). Remove the speculum, and allow the patient to sit up and rest before dressing.

(5) Remove the sampling device, cut off the distal tip, and slowly push the piston completely into the sheath to expel the sample into the fixative.

PITFALL: Do not force the tissue out of the sampling hole without cutting the tip off because this may distort the histologic sample. P.253
CODING INFORMATION


CPT® Code Description 2002 Average 50th Percentile Fee

58100* Endometrial sampling (biopsy), with or without endocervical sampling, without cervical dilatation, any method $170
57800* Dilation of cervical canal, instrumental $133
59200 Insertion of cervical dilator, laminaria $174

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING Catheter-type devices include the Unimar PIPELLE (Pipelle de Cornier), which can be ordered from CooperSurgical, Inc., Shelton, CT (phone: 1-800-243-2974 http://www.coopersurgical.com/), or the Wallach Endocell Endometrial Cell Sampler (20 piece box), which can be ordered from Wallach Surgical Devices, Inc., 235 Edison Road, Orange, CT 06477 (phone: 203-799-2000; fax: 203-799-2002; email:wallach@wallachsurgical.com; http://www.wallachsurgical.com/). BIBLIOGRAPHY Archer DF, Lobo RA, Land HF, et al. A comparative study of transvaginal uterine ultrasound and endometrial biopsy for evaluating the endometrium of postmenopausal women taking hormone replacement therapy. Menopause 1999;6:201–208. Bakour SH, Khan KS, Gupta JK. Controlled analysis of factors associated with insufficient sample on outpatient endometrial biopsy. Br J Obstet Gynecol 2000;107:1312–1314. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993;269:1823–1828. Cicinelli E, Didonna T, Schonauer LM, et al. Paracervical anesthesia for hysteroscopy and endometrial biopsy in postmenopausal women: a randomized, double-blind, placebo-controlled study. J Reprod Med 1998;43:1014–1018. Dijkhuizen FP, Mol BW, Brolmann HA, et al. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer 2000;89:1765–1772. Mishell DR Jr, Kaunitz AM. Devices for endometrial sampling: a comparison. J Reprod Med 1998;43:180-00184. Oriel KA, Schranger S. Abnormal uterine bleeding. Am Fam Physician 1999;60:1371–1380. Tahir MM, Bigrigg MA, Browning JJ, et al. A randomized controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. Br J Obstet Gynaecol 1999;106:1259–1264. Trolice MP, Fishburne C Jr, McGrady S. Anesthetic efficacy of intrauterine lidocaine for endometrial biopsy: a randomized double-masked trial. Obstet Gynecol 2000;95:345–347. Zuber TJ. Endometrial biopsy. Am Fam Physician 2001;63:1131–1135, 1137–1141.

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