Endometrial Biopsy Procedure Steps
Endometrial biopsy is performed by inserting an endometrial suction catheter through the cervix into the uterine cavity, creating suction by withdrawing the catheter's piston, and obtaining tissue by rolling and moving the catheter in and out of the cavity while maintaining suction. 1, 2
Pre-Procedure Preparation
Pain Management
- Administer oral NSAIDs 30-60 minutes before the procedure to reduce cramping and discomfort 1
- Apply topical lidocaine to the cervix before starting to minimize pain 1
- Inform the patient that cramping is a common side effect but serious complications are rare 1, 2
Patient Positioning and Equipment Setup
- Position the patient in dorsal lithotomy position 2
- Perform bimanual examination to assess uterine position and size 2
- Gather sterile endometrial biopsy catheter (such as Pipelle or Vabra device, which have sensitivities of 99.6% and 97.1% respectively for detecting endometrial carcinoma) 3
Procedural Steps
Cervical Preparation
- Apply tenaculum only if absolutely necessary due to cervical mobility or severe uterocervical angulation, as it increases pain and lengthens procedure time 1
- Cleanse the cervix with antiseptic solution 2
Catheter Insertion and Sampling
- Insert the endometrial biopsy catheter through the cervical os into the uterine cavity 1, 2
- Advance the catheter to the uterine fundus 2
- Withdraw the catheter's piston completely to create suction within the device 1, 2
- Roll the catheter between your fingers while simultaneously moving it in and out of the uterine cavity to enhance tissue uptake 1, 2
- Continue sampling from multiple areas of the endometrial cavity 2
- Remove the catheter and express the tissue sample into formalin for pathologic examination 2
Post-Procedure Management
Immediate Care
- Monitor the patient briefly for vasovagal symptoms or excessive cramping 2
- Advise the patient that mild cramping and spotting are normal for 1-2 days 2
Critical Follow-Up Considerations
- A negative endometrial biopsy in a symptomatic patient (especially postmenopausal women) must be followed by fractional D&C under anesthesia, as office biopsy has a false-negative rate of approximately 10% 4, 3
- Never accept an inadequate or negative biopsy as reassuring in symptomatic postmenopausal women—persistent bleeding mandates further evaluation with hysteroscopy 3
- Refer for hysteroscopy with directed biopsy if symptoms persist despite normal initial biopsy, as blind sampling may miss focal lesions such as polyps 4, 3
Common Pitfalls to Avoid
- Do not routinely use a tenaculum unless cervical mobility requires it, as this significantly increases patient discomfort without improving sampling 1
- Do not reassure patients with persistent symptoms based solely on a negative biopsy, particularly in postmenopausal women or those on tamoxifen therapy 3
- Recognize that inadequate samples are more common in postmenopausal women due to endometrial atrophy 5
- Ensure pregnancy has been excluded, as it is the only absolute contraindication to the procedure 1