Overview of Endometrial Biopsy
An endometrial biopsy is a procedure used to check for problems in the lining of the uterus, or womb, often when someone has abnormal bleeding. This is a quick, cost-effective test that allows doctors to closely examine the tissues of the uterus. It’s an important skill for doctors to have because cancer of the uterus is the fourth most common cancer among women.
The American Cancer Society expects that in 2022, nearly 66,000 new cases of uterine cancer will be diagnosed, and about 12,550 women will die from it. The good news is that this type of biopsy is very accurate and can help prevent more invasive procedures. It’s quite good at detecting thickening of the uterus wall (endometrial hyperplasia) and cancer of the uterus lining (endometrial malignancy). In fact, its accuracy is just as good as a more invasive procedure known as dilation and curettage (D&C) which involves opening up the cervix and scraping tissue from the uterus.
Anatomy and Physiology of Endometrial Biopsy
The process of endometrial biopsy involves various anatomical structures or body parts within a woman’s lower abdomen:
1. The body of the uterus, or ‘Uterus Corpus’, is located between the bladder and the rectum. It’s the main part of the uterus where a baby grows during pregnancy.
2. Endometrium is the lining inside the uterus. This delicate layer undergoes changes in thickness throughout a woman’s menstrual cycle.
3. The ‘Myometrium’ is the outer layer of the uterus and is made up mainly of smooth muscle cells. Its contractions play a key role in childbirth.
4. The ‘Cervix’ is located at the bottom of the uterus and contains a canal that connects the uterus and the vagina, or birth canal.
5. The vagina is a passage that connects the lower part of a woman’s uterus (the cervix) to the outside of her body.
Why do People Need Endometrial Biopsy
An endometrial biopsy is a simple procedure where a small piece of endometrial (lining of the uterus) tissue is removed for examination. There could be several reasons your doctor would recommend this procedure:
1. If you are experiencing abnormal uterine bleeding, which could mean bleeding that’s heavier or occurs more frequently than usual, or bleeding that happens between your periods.
2. If your doctor suspects the presence of abnormal cells, or neoplasia, in your uterus, or a condition called precancerous hyperplasia. This condition involves the thickening of the uterine lining and may potentially lead to cancer.
3. If you have been previously diagnosed with endometrial hyperplasia or uterine cancer, your doctor might suggest this procedure to monitor your condition.
4. In cases of hormone therapy, your doctor could recommend an endometrial biopsy to understand how your uterus is responding to the treatment.
All in all, the endometrial biopsy is an essential medical procedure that helps your doctor to understand your uterine condition better and provide appropriate care and treatment.
When a Person Should Avoid Endometrial Biopsy
There are certain conditions under which it’s not safe or appropriate to perform certain medical procedures. Here are some examples:
Absolute contraindications (meaning the procedure should definitely not be done):
– Pregnancy: Pregnancy can cause changes to your body’s function and structure so doing a medical procedure may be risky.
– Acute pelvic inflammatory disease: This is a sudden and severe infection in a woman’s reproductive organs. Performing a procedure in this condition might spread the infection or make it worse.
– Acute cervical or vaginal infection: These are other types of infections in the female reproductive system that make a procedure unsafe.
– Cervical cancer: Performing a procedure on a woman with cervical cancer could potentially spread the cancer cells or complicate her condition.
– Lack of patient consent: Regardless of the circumstance, doctors are legally and ethically required to obtain a patient’s consent before performing a procedure.
Relative contraindications (meaning the procedure should only be done if definitely needed):
– Morbid obesity: People with extreme obesity may face higher risks during a procedure due to potential complications like anesthesia risks, breathing problems, or issues related to the size and positioning of organs.
– Cervical stenosis: This is a condition where the opening of the cervix is too narrow. A procedure might be more difficult to perform and could cause complications.
– Clotting disorder or coagulopathy: This refers to conditions where a person’s blood doesn’t clot properly, increasing the risk of heavy bleeding during and after procedures. Doctors have to be very careful when performing procedures on these patients.
Equipment used for Endometrial Biopsy
To perform a medical procedure called an endometrial biopsy, the doctor needs several tools and items. These include:
– Patient labels: These are tags used to identify the patient to avoid mixups.
– Biopsy container with formalin: A special container where the biopsy sample (small tissue taken from your body) is stored. Formalin is a solution used to preserve this tissue for analysis.
– Speculum: A tool used to gently open up the vagina, allowing the doctor to see inside and reach the cervix more easily.
– Lubricating gel: This helps the speculum slide in more comfortably.
– Sterile and non-sterile gloves: These are worn by the doctor to maintain a clean environment during the procedure.
– Uterine sound: This is a device used to check the depth and direction of your uterus. It helps the doctor know how far to insert other tools.
– Cervical dilators: These are inserted into the cervix to gently open it up, making the procedure easier.
– Single-toothed tenaculum: A tool used to stabilize the cervix during the procedure.
– Ring Forceps: These are used to hold onto and manipulate tissues.
– Iodine swabs: These are used to clean your skin and prevent infection.
– Topical benzocaine gel (20%) or benzocaine spray: These are local anesthetics, used to numb the area and reduce pain.
– An endometrial suction catheter (pipelle) x2: This is a thin flexible tube that’s inserted through the cervix into the uterus to collect a sample of your endometrium (the lining of your uterus).
– 4×4 gauze: This is used to clean the area and absorb any fluid or blood.
– Silver nitrate: This is a chemical used to stop bleeding if there are any small blood vessels that continue to bleed after the procedure.
Who is needed to perform Endometrial Biopsy?
A doctor in a medical clinic can do this procedure alone. But, it can be helpful to have another person to help with getting ready and dealing with the sample taken during the procedure. There aren’t any set rules about having someone else, like a chaperone, present during the exam. While it’s rare for complaints about inappropriate behavior during the exam to happen, doctors might think about using a chaperone.
The American Medical Association suggests that doctors should have a policy that allows patients to ask for a chaperone if they want one. The doctor and their team should make sure patients know about this policy. Anyone from the medical team can act as a chaperone, as long as they agree to respect the patient’s privacy and confidentiality.
Preparing for Endometrial Biopsy
If you’re having a medical test or treatment, such as a biopsy of the lining of your womb (also known as endometrial biopsy), it’s normal to feel nervous. This specific procedure often causes anxiety in many patients. In some cases, it can cause much higher levels of distress, especially in those who have been through difficult experiences, such as sexual abuse or assault.
If you feel uncomfortable or scared at any point, it’s vital that you tell your doctor or nurse. They’re there to help you and if the procedure is causing you distress, they can stop at any time. In some situations, it might be helpful to bring in a trained therapist or social worker to help you manage your feelings about the procedure. This is always an option if the stress and anxiety are making it too difficult to proceed.
Before the procedure, the doctor will usually request a pregnancy test for women who could potentially be pregnant. This is to make sure the procedure is safe for you.
Taking a painkiller from a group of medications called nonsteroidal anti-inflammatory drugs (or NSAIDs for short) about 30 to 60 minutes before the procedure can help lessen any possible cramping pain. Your doctor can provide you with more advice on this.
Usually, antibiotics aren’t required before this procedure, as there’s no considerable risk of an infection or inflammation of the heart (known as bacterial endocarditis) from it.
How is Endometrial Biopsy performed
The patient should undress from the waist down, staying covered with a sheet for privacy. The sheet is only removed as needed for the medical procedure. Initially, the procedure doesn’t need to be sterile. The patient is put in a position with their legs apart (referred to as the “lithotomy position”), and a doctor carries out a hands-on examination to understand the size and position of the uterus. After this, a medical tool called a speculum is used to help the doctor see the cervix (opening of the uterus). If a Pap smear (a test to check for abnormal cells in the cervix) is needed, this can be done before proceeding with the procedure. Once the cervix can be seen, it is numbed and cleaned with a 20% benzocaine spray and an iodine solution. At this stage, the doctor will wash hands and put on sterile gloves.
Next, the doctor determines the depth of the uterus. This is done by using a tool called a uterine sound. The first step is to stabilize the cervix with a tool called a tenaculum placed on the front part of the cervix. This helps the doctor to straighten the angle between the uterus and the cervix. The uterine sound is then inserted to an average depth of 6 to 10 cm within the uterus. The doctor can feel when the sound is fully inserted as there will be resistance from the top part of the uterus (fundus). In case the sound cannot pass through the inner opening of the cervix, the cervix can be dilated using size-increasing tools. The smallest size is used first, then larger ones until the sound can reach the fundus.
Once the inner opening of the cervix has been dilated enough and the doctor has determined the uterus’s depth, the sampling device called a pipelle can be inserted. The pipelle should be moved forward until resistance is felt. This resistance should be at the same depth as measured during the insertion of the sound. The pipelle has a suction feature at the tip which is used by moving the pipelle in and out in order to collect the tissue sample. It is also rotated 360 degrees to ensure samples from all areas of the endometrium (inner lining of the uterus) are collected. The pipelle is then removed, and the collected tissue sample is put in a preserving fluid called formalin. This procedure can be repeated to ensure enough tissue has been collected.
When the procedure is completed, the tenaculum is gently removed. If there’s bleeding, it can usually be controlled with pressure via cotton swabs or a sponge stick. If bleeding continues, the site may be treated with silver nitrate sticks which help to stop the bleeding. After the procedure, the patient is allowed to stay half-sitting for as long as they need to avoid any fainting-like reactions. Guidelines vary, but many doctors and hospitals advise patients that they can bathe or shower immediately after the procedure. However, they should avoid sexual intercourse or inserting any device into the vagina until any bleeding has stopped.
Possible Complications of Endometrial Biopsy
The most usual side effect of a procedure called an endometrial biopsy, which is a test where a small piece of the lining of the womb (endometrium) is taken for examination, is a pain similar to menstrual cramps. Taking non-steroidal anti-inflammatory drugs (NSAIDs), which are common painkillers like ibuprofen, before the procedure can greatly lessen this cramping. After the procedure, women might experience light bleeding or spotting from their vagina for several days.
Less common side effects can include perforation of the uterus (when a small hole is accidentally made in the womb), pelvic infection (an infection in the lower part of your belly), and bacteremia (when bacteria enter the bloodstream). To monitor for these complications, patients are given a set of return precautions. These are signs to look out for that indicate they should return to the doctor’s office. These signs include fever, cramping that lasts for more than 48 hours, increased pain, bleeding heavier than a normal menstrual period, or any oddly smelling discharge.
What Else Should I Know About Endometrial Biopsy?
An endometrial biopsy is a simple and safe procedure that doctors use to check for problems in the lining of your uterus, especially if you’re having abnormal bleeding or if you’re bleeding after menopause. This test is often done in the doctor’s office and can help find out the cause of the bleeding. It’s very important to investigate if you experience bleeding after menopause as it might signal a problem.
Experts including the Society of Radiologists in Ultrasound agree that an endometrial biopsy or an ultrasound that is performed through the vagina (known as transvaginal ultrasonography) are both great starting points when examining postmenopausal bleeding. In fact, research has found that an endometrial biopsy is just as effective as a more invasive procedure called dilation and curettage when it comes to identifying uterine cancer.
So, if you’re dealing with abnormal bleeding from the uterus, an endometrial biopsy should be one of the first tests your doctor considers. It’s a trusted method used to look at the cells from your endometrium (the lining of the uterus) to detect any abnormalities.
