Endometrial Biopsy

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  • Evaluation of premenopausal and postmenopausal abnormal uterine bleeding
  • Workup for infertility, especially short luteal phase or anovulation
  • Assessment of the effects of hormone therapy
  • Investigation of atypical glandular cells of undetermined significance (AGUS) on Pap smear in women older than 40 years of age
  • Failure to respond to medical treatment for abnormal uterine bleeding
  • Evaluation of abnormal endometrial thickness on transvaginal ultrasound
  • Surveillance in women previously given the diagnosis of endometrial hyperplasia
  • Abnormal uterine bleeding in women with risk factors for endometrial cancer
  • Women with an intact uterus receiving unopposed estrogen therapy
  • Evaluation for endometrial carcinoma or precancerous changes
  • Identification of causes of dysfunctional uterine bleeding
  • Evaluation of uterine enlargement (in conjunction with ultrasonography)
  • Screening for hereditary nonpolyposis colon cancer syndrome (HNPCC)

Absolute Contraindications

  • Pregnancy
  • Bleeding diathesis/coagulopathy

Relative Contraindications

  • Use of anticoagulant therapy
  • Active vaginal, cervical, uterine, or pelvic infection
  • Cervical stenosis
  • Morbid obesity
  • Significant pelvic relaxation with uterine prolapse

Equipment Common to All Methods (Sterile)

  • Large Graves' vaginal speculum
  • Povidone-iodine solution (in nonallergic patients)
  • Cotton balls
  • Ring forceps
  • Uterine sound
  • Single-toothed tenaculum
  • Topical benzocaine gel (20%) or benzocaine spray (Hurricane) (optional)
  • Endocervical curette without basket (e.g., Kevorkian endometrial curette)
  • Buffered formalin specimen containers with patient identification labels (two)
  • Endometrial Aspirator


  • The endometrial lining consists of mucosal tissue that varies in thickness (1-6 mm).


  • The cervical arteries lie at the 3- and 9-o'clock positions on the cervix.
  • Endocervical sampling can cause a reflex bradycardia and a vasovagal response.

Endocervical Canal

  • The size of the endocervical canal is variable, but usually it is 2.5 to 3 cm long and up to 8 mm wide in the middle (usually the widest point).

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  • Patients should remain semi-recumbent for 10 minutes. Assess for vasovagal reaction.
  • Painful uterine cramps usually subside rapidly or are relieved by NSAIDs.
  • Patients with minimal cramping and bleeding may be discharged home.
  • Consider a follow-up visit to discuss pathology findings. If bleeding persists, further evaluation is indicated.
  • Advise the patient that bleeding and cramping usually resolve within 24 to 48 hours.
  • Sexual relations may be resumed after bleeding has stopped.
  • Uterine perforation.
  • Excessive uterine bleeding is possible.
  • Missed pathology is possible.
  • A vasovagal response occurs in an estimated 10% of patients after endometrial biopsy.
  • Pain after the procedure generally is minimal.
  • Bacteremia, septicemia, and endocarditis have been reported (rare).
  • Biopsy interpretation
    • Inadequate samples are possible in biopsies immediately after menses, with hypoestrogenism, with prolonged bleeding, or with intrauterine adhesions/synechiae.
  • Endometrial hyperplasia
    • Endometrial hyperplasia is classified according to guidelines from the International Society of Gynecological Pathologists or the World Health Organization (WHO).
    • Both hyperplasia and atypical hyperplasia are categorized as simple or complex.
    • Endometrial hyperplasia without cytologic atypia usually is managed with 20 mg of medroxyprogesterone acetate given twice daily for 3 to 6 months.
    • Hyperplasia with cytologic atypia is best managed with a hysterectomy because of the risk for progression to adenocarcinoma.
  • Histology determines management.
    • The severity of endometrial hyperplasia and the probability of cancer cannot be determined by the amount of bleeding, the point at which bleeding occurs in the menstrual cycle, the gross appearance of the sample, or the tissue volume obtained by biopsy.
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