Endometrial biopsy
An endometrial biopsy is a medical procedure used to collect a sample of tissue from the lining of the uterus (endometrium) to diagnose various conditions, particularly when abnormal uterine bleeding occurs. This abnormal bleeding may manifest as excessive duration, frequency, or unexpected timing, including bleeding after menopause. The biopsy is often essential for ruling out serious conditions such as endometrial cancer or hyperplasia, especially in women experiencing perimenopausal symptoms or those undergoing hormone therapy.
The procedure, typically performed in an office setting by an obstetrician, gynecologist, or trained medical professional, involves the insertion of a small tube through the cervix into the uterus to suction out a tissue sample. Though it generally requires no anesthesia, mild over-the-counter pain relief is recommended beforehand to manage discomfort. While some cramping or light spotting is expected post-procedure, serious complications are rare, though immediate medical attention is advised for symptoms like heavy bleeding or severe pain.
Endometrial biopsies have evolved significantly since their inception in the 19th century, with modern devices like the Pipelle curette enhancing comfort and accuracy. This procedure plays a critical role in fertility assessments and the diagnosis of conditions such as endometritis and luteal phase defects, guiding further treatment options when necessary.
Endometrial biopsy
Anatomy or system affected: Genitals, reproductive system, uterus
Definition: A procedure in which a tissue sample is taken from the lining of the uterus and then examined
Indications and Procedures
An endometrial biopsy is usually performed to identify the cause of abnormal uterine bleeding. Abnormal bleeding is that which is excessive in duration, frequency, or amount for the particular woman, and it includes bleeding at the wrong times (between menstrual periods) or after menopause. The biopsy may also be performed when there is no bleeding (or menstruation) or if a woman is having difficulty becoming pregnant.
Most women who have endometrial cancer have abnormal bleeding, so the biopsy is performed to rule out both cancer and hyperplasia, an excessive growth of tissue that could become cancerous. Women who are perimenopausal (prior to the actual end of menstrual cycles) may experience changes in their cycle that make it difficult to determine if there is abnormal bleeding or simply normal changes. Perimenopause varies in length but usually begins six to eight years before menopause, and then women become menopausal when menstrual cycles end. Women on hormone therapy are at greater risk of endometrial cancer because they usually take the hormonesestrogen and progesterone that their body is no longer producing at sufficient levels. Women who take estrogen but cannot take progesterone are at an even greater risk of endometrial cancer.
The biopsy may also be used as part of an infertility examination to determine whether there are problems with the development of the endometrium. If the endometrium does not thicken in time to accept and support a fertilized egg, then the egg cannot implant properly, a condition called "luteal phase defect" (LPD). The biopsy can show whether the uterine lining is thickening and maturing by developing more blood vessels before menstruation, a definite sign that ovulation (the maturation and release of an egg by the ovary) has occurred and that the lining can support a pregnancy. Additionally, the biopsy may be performed to help evaluate the problem of repeated early miscarriages. Another use of the procedure is to obtain a sample for patients with suspected endometritis or polycystic ovary disease.
An obstetrician or gynecologist (or, in some cases, a nurse practitioner or nurse midwife) will perform the procedure, which is usually done in an office setting. The procedure takes a few minutes, and no anesthesia is needed, although a mild over-the-counter painkiller such as ibuprofen is often recommended about one hour before the procedure to ease discomfort. In cases of cervical stenosis, cervical softening may be accomplished by administration of the medication misoprostol. Additionally, a local anesthetic may occasionally be injected into the cervix to decrease pain and discomfort.
After a pelvic examination, the clinician will insert a speculum into the vagina to hold the walls open. After the cervix is cleaned with antiseptic, a tiny hollow plastic tube is inserted into the vagina, through the cervix, and into the uterus. A plunger attached to the tube will suction out a sample of the inner layer of tissue in the uterine wall. The tube is turned clockwise or counterclockwise while being moved in and out of the uterine cavity to obtain specimens. The cells are then sent to a laboratory for testing and microscopic examination.
Uses and Complications
Mild cramping may occur during and after the procedure. Cramping, pressure, and discomfort may also occur when the instruments are inserted and the samples collected. A small amount of bleeding, or spotting, may occur afterward, although normal activities can be resumed immediately.
After the procedure, there are slight risks of infection or heavy bleeding. Heavy bleeding, severe pain or cramping, or a fever over one hundred degrees Fahrenheit (about thirty-eight degrees Celsius) requires immediate medical attention. Extremely rarely, the uterus may be injured or punctured by the tool, or the cervix may be torn during the procedure. The procedure should not be performed if the patient is pregnant or suffers from acute pelvic inflammatory disease, or acute cervical or vaginal infections.
Abnormal cells may indicate endometrial cancer, LPD, the presence of fibroids (benign or noncancerous, excessive growths of the smooth muscle wall of the uterus), or polyps (a usually benign growth of normal tissue attached to the lining of the uterus). Surgery and/or medication may be necessary to treat these conditions.
Ultrasound is often utilized along with endometrial sampling for initial evaluation. Patients with persistent symptoms may need additional tests and procedures. Because an endometrial biopsy often misses polyps and fibroids, alternative procedures such as dilation and curettage (D&C) or hysteroscopy may be used for further diagnostic purposes.
Perspective and Prospects
The use of endometrial sampling to diagnose and treat problems has been practiced since at least 1843. The earliest tools were wide and required scraping the uterine lining. Later devices, such as the stainless-steel Novak (or Kevorkian) curette or Vabra aspirator, cause significant discomfort. The Novak curette requires a syringe to apply suction. The Vabra aspirator is a disposable device that uses an electric suction pump to obtain the sample.
By 2006, the most used tool for endometrial biopsies was the Pipelle curette, developed in France. The curette is narrower, more flexible, and easier to insert through the cervix, and it removes the sample by suction. This device is relatively inexpensive, causes little to no discomfort to the patient, and has been shown to obtain adequate specimens in 87 to 100 percent of patients. In the later decades of the twenty-first century, the Pipelle curette remained the most commonly used tool in endometrial biopsy though the device had undergone several adaptations to increase the tool’s convenience and the patient’s comfort.
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