Endometrial Biopsy: Tips and Pitfalls

 

Am Fam Physician. 2020 May 1;101(9):551-556.

  Patient information: See related handout on endometrial biopsy, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Endometrial biopsy is a safe and efficient method to evaluate the endometrium for a variety of indications, most commonly abnormal uterine bleeding and postmenopausal bleeding. Endometrial biopsy is highly specific for diagnosing atypical hyperplasia and endometrial cancer in postmenopausal women. Pregnancy is the only absolute contraindication to the procedure. The biopsy is performed with an endometrial biopsy catheter that is inserted through the cervix into the uterine cavity. The catheter's piston is then drawn out to create suction. Tissue sampling occurs by rolling the catheter while moving it in and out of the uterine cavity. Nonsteroidal anti-inflammatory drugs can be administered orally before the procedure, and topical lidocaine can be applied to the cervix before starting the procedure to reduce procedure-associated pain. A tenaculum should be applied only if required by cervical mobility or uterocervical angulation because it increases pain and lengthens procedure times. Cramping is a common adverse effect, but serious complications are rare. Patients should be referred for further evaluation if the procedure fails or an insufficient sample is obtained. Postmenopausal women and women with persistent or recurrent symptoms should receive further evaluation even when biopsy results are normal because blind sampling may miss focal lesions.

Endometrial biopsy is a safe, efficient, and cost-effective method for evaluating the endometrium.1,2 This office procedure is commonly performed for evaluation of abnormal uterine bleeding and postmenopausal bleeding; the evaluation may also include imaging studies such as transvaginal ultrasonography, sonohysterography, or hysteroscopy.3,4 In postmenopausal women, an endometrial biopsy is 90% sensitive for endometrial cancer and 82% sensitive for atypical hyperplasia; the specificity is nearly 100% for both.5 Premenopausal women have similar outcomes.6 The current reasonable fair price for this procedure is $750.7

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Endometrial biopsy should be performed for patients with abnormal uterine bleeding who are 45 years or older, and in younger patients with a significant history of unopposed estrogen exposure, persistent bleeding, or in whom medical management is ineffective.4,8

C

Expert opinion and consensus guidelines in the absence of clinical trials

Women with postmenopausal bleeding but no risk factors for endometrial hyperplasia or cancer may have transvaginal ultrasonography or endometrial biopsy as a first-line approach to evaluation.3

C

Expert opinion and consensus guidelines in the absence of clinical trials

Do not routinely use oral misoprostol (Cytotec) before endometrial biopsy.21,22

B

Two randomized controlled trials demonstrating more adverse effects without increased ease of biopsy

Consider using topical lidocaine to reduce procedure-associated pain during endometrial biopsy.23

A

Systematic review and meta-analysis of randomized controlled trials with consistent findings showing reduced biopsy-associated pain


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Endometrial biopsy should be performed for patients with abnormal uterine bleeding who are 45 years or older, and in younger patients with a significant history of unopposed estrogen exposure, persistent bleeding, or in whom medical management is ineffective.4,8

C

Expert opinion and consensus guidelines in the absence of clinical trials

Women with postmenopausal bleeding but no risk factors for endometrial hyperplasia or cancer may have transvaginal ultrasonography or endometrial biopsy as a first-line approach to evaluation.3

C

Expert opinion and consensus guidelines in the absence of clinical trials

Do not routinely use oral misoprostol (Cytotec) before endometrial biopsy.21,22

B

Two randomized controlled trials demonstrating more adverse effects without increased ease of biopsy

Consider using topical lidocaine to reduce procedure-associated pain during endometrial biopsy.23

A

Systematic review and meta-analysis of randomized controlled trials with consistent findings showing reduced biopsy-associated pain


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST P

The Authors

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PAMELA M. WILLIAMS, MD, FAAFP, is the associate dean for student affairs and an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

HEIDI L. GADDEY, MD, is the director of medical education and the designated institutional official at David Grant Medical Center, Travis Air Force Base, Calif.

Address correspondence to Pamela M. Williams, MD, C1020A, 4301 Jones Bridge Rd., Bethesda, MD 20814 (email: pamela.williams@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

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