Biopsia Endometrial PDF

Preview

Summary

resumen detallado de la biopsia...

Description

The

n e w en gl a n d j ou r n a l

of

m edic ine

videos in clinical medicine

Endometrial Biopsy Paul Gordon, M.D., M.P.H. Indications

Endometrial biopsy is one type of endometrial evaluation recommended by the American College of Obstetricians and Gynecologists for evaluating the tissue lining the uterus. There are many indications for endometrial biopsy. These include abnormal uterine bleeding, postmenopausal bleeding, and evaluation of a patient with 1 year of amenorrhea. Additional indications include endometrial dating to define the phase of the menstrual cycle, evaluation of infertility, and evaluation of uterine response to hormone therapy. Finally, endometrial biopsy is indicated in women whose Papanicolaou (Pap) smear has shown atypical glandular cells and those who need follow-up for previously diagnosed endometrial hyperplasia. A consensus panel from the Society of Radiologists in Ultrasound determined that either endometrial biopsy or transvaginal ultrasonography is effective as a first diagnostic step in the evaluation of postmenopausal bleeding.1 The sensitivity and specificity of transvaginal ultrasonography are related to whether the radiologist is using a threshold thickness of 4 mm or 5 mm for further assessment. The role of transvaginal ultrasonography in premenopausal women with bleeding abnormalities has not been established.2 Finally, endometrial biopsy is more costeffective than transvaginal ultrasound when the prevalence of endometrial carcinoma is 15% or more.3

From the Department of Family and Community Medicine, University of Arizona College of Medicine, Tucson. Address reprint requests to Dr. Gordon at 1501 N. Campbell Ave., Tucson, AZ 85724-5113, or at [email protected]. N Engl J Med 2009;361:e61. Copyright © 2009 Massachusetts Medical Society.

Contraindications

Specific contraindications to endometrial biopsy include pregnancy, acute pelvic inflammatory disease, clotting disorders, acute cervical infections, and cervical cancers. Equipment

The procedure for endometrial biopsy has a nonsterile and a sterile component. The equipment used for the nonsterile component includes gloves, lubricating gel, a vaginal speculum, a formalin container, large cotton swabs, and various forms of anesthesia or analgesia. These include nonsteroidal antiinflammatory drugs (NSAIDs), 20% benzocaine spray or 20% benzocaine gel, and 5 cc of 2% lidocaine. After preparing the nonsterile equipment, put on sterile gloves to begin the sterile part of the procedure. The equipment includes ring forceps, gauze sponges soaked in chlorhexidine or povidone–iodine, tenaculum forceps, a uterine sound, an endometrial suction catheter or aspirator, and cervical dilators. Since cervical dilators are not always needed, you should have these available but leave them unopened. There are multiple endometrial suction devices, including the pipelle device, manual vacuum aspirator, gynecologic cannula, and endometrial brush. They have been shown to be equally reliable. The pipelle is generally considered more comfortable for the patient and is used in the video.

n engl j med 361;26

nejm.org

december 24, 2009

The New England Journal of Medicine Downloaded from nejm.org by Renatta Farfán on May 25, 2020. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.

e61

The new england journal of medicine

Preparation

Explain the procedure to the patient at the time of referral or scheduling. You should explain that the techniques are very similar to those used when doing a pelvic examination to obtain a Pap smear, but with additional components. These include the grasping of the cervix with the tenaculum, the potential need to dilate the cervix, and the scraping of the endometrium. All these activities generally cause some cramping, often more marked than menstrual cramps. You may advise the patient to take an NSAID 30 to 60 minutes before the procedure. Obtain informed consent from the patient. Although written informed consent is generally preferred, you should follow your institutional guidelines. The Procedure

Figure 1. Use of the Tenaculum to Grasp the Cervix.

Endometrial biopsy is a relatively simple office-based procedure. With practice, you should be able to perform it in less than 8 minutes. As noted earlier, the initial part of the procedure is not sterile. After washing your hands, put on examination gloves and begin the procedure with a bimanual examination to assess the size and the position of uterus. Then insert the speculum and visualize the cervix.4 If a Pap smear or culture is indicated, obtain the samples before continuing with the remainder of the procedure. Now apply benzocaine gel or spray. At this time, you should wash your hands again and put on sterile gloves. Clean the cervix with chlorhexidine gluconate or povidone–iodine. Patients who are allergic to povidone may be prepped with nonchlorhexidine antibacterial soap and water followed by alcohol. Using an 18-gauge catheter sheath, inject 5 cc of 2% lidocaine through the cervix into the uterine cavity. Keep the catheter in the uterus for 3 minutes to limit backflow of the lidocaine and to allow the anesthetic to become effective.5 Insert a uterine sound to an approximate depth of 6 to 10 cm within the uterus. You will know that the sound is fully inserted when you encounter the resistance of the uterine fundus. The uterine sound can often be inserted through the cervical os without the aid of a tenaculum. If you cannot pass the sound through the os, grasp the anterior lip of the cervix horizontally with the tenaculum (at 10 o’clock and 2 o’clock, visualizing the cervix as the face of a clock) and pull out on the tenaculum to straighten the endocervical canal (Fig. 1). Pulling on the tenaculum to create gentle cervical traction, proceed with the insertion of the sound. If you are still unable to pass the sound through the os, use a series of small (1-to-4-mm) cervical dilators to dilate the canal. With the os now adequately dilated, insert the pipelle into the os (Fig. 2) and advance it until you encounter resistance. This resistance should be at the same depth as the sounding of the uterus. Next, withdraw the inner piston of the pipelle to create suction. You can collect the sample by moving the pipelle in and out and rotating it 360 degrees through the four quadrants of the endometrium. Do not use more than four revolutions. Do not let the sheath come outside the external os until you have completed the procedure. You can now remove the pipelle and express the contents into a solution of 10% formalin. You may repeat the collection procedure as long as the pipelle remains uncontaminated, keeping the pipelle from contacting the formalin. Remove the tenaculum and use cotton swabs to control any bleeding from the tenaculum site, then remove the speculum. Aftercare

Figure 2. Insertion of the Pipelle through the Cervix into the Uterus.

To reduce the chance of a vasovagal episode, keep the patient in a semirecumbent position on the examination table for several minutes after the procedure. After

n engl j med 361;26

nejm.org

december 24, 2009

The New England Journal of Medicine Downloaded from nejm.org by Renatta Farfán on May 25, 2020. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.

Endometrial Biopsy

the patient gets up, she may leave the office and resume her usual activities, provided she is not light-headed and there is no heavy bleeding. Arrange a follow-up plan with the patient to discuss the pathology results. Cramping during the procedure is often relieved when the procedure ends. If the patient took an NSAID before the procedure but continues to have cramping after the procedure, she can take another dose at the appropriate interval. Tell the patient that she may resume her usual activities at her discretion. However, she should not use tampons or have sexual intercourse for 14 days. Tell the patient that she needs to call the office if she has fever, cramping continuing for more than 48 hours, increasing pain, bleeding heavier than a normal menstrual period, or a foul-smelling discharge. Less common side effects include excessive bleeding (consider undiagnosed coagulopathy), uterine perforation, pelvic infection, and bacteremia. Troubleshooting

Endometrial biopsy may lead to a number of complications. First, it may be too difficult to pass the catheter through a stenotic os, which may be present, particularly in perimenopausal or postmenopausal women. In such instances, placement of a 3-mm osmotic laminaria dilator derived from seaweed often results in dilatation of the os within several hours. Insert this dilator in the morning and then complete the procedure in the afternoon. Application of estrogen cream daily for 4 to 5 days before the procedure and use of a paracervical block can also be helpful. A second problem is obtaining an inadequate specimen. Resampling can help to ensure that the specimen is adequate. It is important not to contaminate the pipelle when emptying the specimen into the formalin so that additional passes with the same pipelle can be taken. The pipelle should not make contact with the formalin if you plan to reuse it. Third, you may find that the tenaculum causes pain for the patient. Use of benzocaine spray or gel may help ease this pain.

Refer ences Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med 2001;20:1025-36. 2. Breitkopf DM, Frederickson RA, Snyder RR. Detection of benign endometrial masses by endometrial stripe measurement in premenopausal women. Obstet Gynecol 2004;104:120-5. 3. Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. Cost-effectiveness of the use of transvaginal sonography in the evaluation of postmenopausal bleeding. Maturitas 2003;45:275-82. 4. Edelman A, Anderson J, Lai S, Braner DA, Tegtmeyer K. Pelvic examination. N Engl J Med 2007;356(26):e26. (Available at NEJM.org.) 5. Dogan E, Celiloglu M, Sarihan E, Demir A. Anesthetic effect of intrauterine lidocaine plus naproxen sodium in endometrial biopsy. Obstet Gynecol 2004; 103:347-51.

1.

Copyright © 2009 Massachusetts Medical Society.

Summary

Endometrial biopsy is an office-based method used to evaluate the tissue lining of the uterus. It is one type of endometrial evaluation recommended by the American College of Obstetricians and Gynecologists for assessment of postmenopausal uterine bleeding, uterine response to hormone therapy, and atypical glandular cells, if present. The technique used is very similar to that used when doing a pelvic examination but adds the components of grasping the cervix with a tenaculum, entering the uterus, and then scraping small samples from the endometrial lining. Complications are rare. This procedure is an important component of office practice for assessing the endometrium. No potential conflict of interest relevant to this article was reported.

n engl j med 361;26

nejm.org

december 24, 2009

The New England Journal of Medicine Downloaded from nejm.org by Renatta Farfán on May 25, 2020. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved....