Guidelines 2016 – Endometrial Biopsy
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
endometrial biopsy is a method of obtaining a sample of the nonpreg- nant uterine lining for purposes of cytologic and histologic examination. the procedure can be done in an ambulatory setting with or without local anesthesia.
II. ETIOLOGY
a. reasons for performing this diagnostic procedure may include
1. unexplained abnormal vaginal bleeding in the premenopausal, perimenopausal, or postmenopausal woman
2. rule out endometrial pathology prior to initiation of hormone therapy (Ht), if indicated in the postmenopausal woman, and periodically monitor endometrial status with unopposed estro- gen use, if indicated.
3. Determine response of the endometrium to hormonal interven- tion in women experiencing infertility.
4. evaluate endometrial response during tamoxifen therapy to rule out pathologic response.
III. HISTORY
a. What the patient may present with
1. unexplained abnormal vaginal bleeding in a premenopausal, perimenopausal, or postmenopausal woman, with or without Ht
2. unsuccessful attempts at pregnancy
3. Current tamoxifen therapy for breast disease
B. additional information to be considered:
1. Ht: type, purpose, duration, dosage, side effects, bleeding history; use of hormonal contraception, iuD
2. Gynecologic history and pregnancy
3. Gynecologic surgery, including previous endometrial biopsies and results, tubal ligation, cesarean section
4. Medical conditions: cardiac, bleeding disorders, hypoglycemia
5. Current medications, including otC and botanical preparations
6. allergies to pharmacologics, including local anesthetic agents and povidone-iodine (Betadine, similar products)
7. Vasovagal episodes, especially with pelvic examinations, uterine sounding, iuD insertion, elective abortion
8. symptoms of vaginitis, cervicitis, sti, PiD
9. Contraceptive methods, including current method and consis- tency of use; any recent exposure to pregnancy risk and date
10. Menstrual cycles, peri- and postmenopausal bleeding; last men- strual period, previous menstrual period
11. General status: last meal or snack, fluids (rule out hypoglycemia); offer juice or snack
IV. PHYSICAL EXAMINATION
a. Prior to exam (20 minutes), consider administering a mild prostaglan- din inhibitor
B. Bimanual examination: uterine position, pain, flexion, size, shape, adnexal or uterine masses, cervical motion tenderness, adnexal exam; any pelvic pain; determine involution if woman is postpartum, postabortion
C. speculum exam, presence of vaginal discharge
D. Cervical inspection, position, presence of polyps, nebothian cysts, iuD string, mucopurulent discharge
e. rectovaginal examination to determine uterine size, position, rule out pregnancy
F. Vital signs
1. Blood pressure
2. temperature (rule out fever)
G. teach woman about the procedure and possible complications and obtain her consent to proceed
V. REASONS TO DEFER PROCEDURE
a. Pregnancy or possible pregnancy
B. PiD, sti with PiD as complication, cervicitis
C. Poor involution of uterus postpartum or postabortion
D. Fever
e. Blood dyscrasias, especially bleeding disorders, severe anemia
F. extremely anteflexed or retroflexed uterus or cervical stenosis—may need to do biopsy under general anesthesia
G. Vaginitis: defer procedure until diagnosis and treatment regimen completed
VI. LABORATORY EXAMINATION
a. Pregnancy test
B. Hematocrit as indicated
C. Vaginal and cervical cultures as indicated
D. Postprocedure biopsy specimen(s) for histologic screening
e. other per workup for abnormal uterine bleeding
VII. BIOPSY TECHNIQUE
a. Cleanse cervix and vagina with antiseptic, considering any sensitivi- ties, allergies.
B. administer local anesthetic agent to the cervix (lidocaine gels, other topical gel or spray products, or paracervical block) if necessary/ desired, depending on sampling technique and equipment to be used.
C. sound the uterus (if using curette for sampling); prior to this, grasp- ing the cervix with a fine tenaculum is necessary (using local anes- thetic gel at the site for tenaculum placement reduces pain for the woman). Having the patient cough when applying and removing the tenaculum often reduces discomfort.
D. insert the sampling device in the os, taking care not to force the device through a resistant os. if the os is stenotic, cervical dilators may be used. use one of the following techniques.
1. Pipelle device (flexible sampler with a piston to create suction for sampling): insert up to fundus. Pull back completely on the pis- ton to create suction and rotate the pipelle continuously, moving it from the fundus and back again several times to collect the sample completely, filling the plastic tube. Withdraw the pipelle and push in the piston to deposit sample into the preservative. some devices require cutting off the tip to expel the specimen.
2. Pipelle device attached to suction pump: insert as previously men- tioned and collect specimen by connecting the external pump, con- tinuing suction until the device is filled.
3. suction curette that is steel and reusable or plastic and disposable: sound the uterus, stabilizing the cervix with a tenaculum, and then insert the curette and gently sample in a manner similar to using the pipelle devices (some are attached to a 10-ml syringe to provide the suction and some to an external pump). Withdraw the curette, deposit the specimen in the preservative.
e. Monitor patient’s condition during and after the procedure to assess for vasovagal response, signs, and symptoms of uterine perforation
F. allow patient to rest briefly with her legs flat before getting off the examination table. ensure that she is not feeling faint and is able to get dressed safely.
G. instruct patient about postprocedure care.
1. signs and symptoms of complications are severe cramping or pel- vic pain; bright red bleeding with or without clots; fever, chills, foul-smelling vaginal discharge—call provider and/or go to urgent care setting.
2. expect spotting for 1 to 2 days after the biopsy; define spotting and the difference between spotting and bleeding.
3. Patient may resume vaginal intercourse in 3 days or whenever she desires.
4. Prostaglandin inhibitor for mild cramping
5. resumption of menses if premenopausal and having menstrual cycles
VIII. REFERRAL/CONSULTATION FOR PROCEDURE
a. Patients with severe cervical stenosis to consider procedure under general anesthesia
B. Patients with contraindications for procedure
IX. FOLLOW-UP
a. arrange for an opportunity to review laboratory findings
B. Care based on reason for endometrial biopsy and laboratory results
C. treatment for any positive culture results
X. REFERRAL/CONSULTATION FOR RESULTS
a. endometrial carcinoma: referral for treatment or comanagement
B. Hyperplasia without atypia: usually means atrophic changes
1. secretory: follow but no need for treatment unless bleeding persists and consider a progestin
2. Proliferative may benefit from a progestin.
C. Complex hyperplasia without atypia
1. Desires pregnancy: consider risks and comanage with physician
2. Does not desire pregnancy: to remove unopposed estrogen, cycle with progestins and repeat endometrial biopsy in 3 to 6 months.
D. Complex hyperplasia with atypia—referral for D&C
1. Comanagement for pregnancy if desired and no malignancy or for surgical high risk
2. surgery and/or treatment per staging if malignant
3. Hysterectomy if nonmalignant and no pregnancy desired
See Bibliographies.
Website: www.medicinenet.com/endometrial_biopsy/article.htm