Ultrasound examination before, during, and after office endometrial sampling
© Springer-Verlag Berlin Heidelberg 2013
Received: 14 September 2013
Accepted: 27 November 2013
Published: 10 December 2013
Office endometrial sampling is widely used as the first diagnostic test in women with abnormal uterine bleeding. Because office sampling is a blind procedure, the lesion causing the symptoms may be missed. The use of ultrasound before, during, and after office endometrial sampling improves relevant tissue yield. The measurement of the endometrial thickness informs if sampling is indicated. The evaluation of ultrasound features (without or with fluid instillation) may suggest a focal intracavitary lesion necessitating operative hysteroscopy. The knowledge of the uterine cavity length, shape, and flexion may avoid nonrepresentative sampling. The concordance between the tissue yield and the ultrasound findings reflects the reliability of the sampling. If not concordant, further diagnostic steps such as fluid instillation sonography or hysteroscopy are indicated. We conclude that integrating ultrasound in the diagnostic algorithm for uterine intracavitary pathology optimizes office endometrial sampling.
KeywordsUltrasonography Uterus Endometrium Leiomyoma Metrorrhagia
Most practitioners favor office endometrial sampling as the first diagnostic test in women with abnormal uterine bleeding. The main reason is that tissue diagnosis is considered pivotal. Depending on the histology of the endometrial sample, further management is planned. The alleged medico legal value of a pathology report is an additional reason in favor of endometrial biopsy. However, because office sampling is a blind procedure, there is no control that the tissue yielded is representative for the patient's problem. If a relevant lesion is missed, management is likely to be inappropriate.
Many benign focal intracavitary lesions, such as endometrial polyps or intracavitary fibroids will not be picked-up by office sampling . Although they are not life threatening, polyps and fibroids cause abnormal bleeding both before and after menopause. It is therefore relevant not to overlook benign focal lesions.
The value of ultrasound before, during, and after office endometrial sampling to improve relevant tissue yield will be discussed in this paper.
Ultrasonography before endometrial sampling
The uterine cavity length, the uterine flexion, and the possible presence of an intracavitary fibroid or a cesarean section scar defect assessed by transvaginal ultrasound enable the clinician to ascertain that the sampling device will be introduced deep enough and that the endometrial sample will be representative. One should be aware that sampling disturbs the ultrasound features of the endometrium . The endometrial thickness, as well as other ultrasound characteristics such as the endometrial outline or the echogenicity of the endometrium is altered by the sampling procedure. This is another incentive to perform an ultrasound examination before proceeding with office endometrial biopsy.
Ultrasonography during endometrial sampling
Ultrasonography after endometrial sampling
Both FIS and hysteroscopy have a similar diagnostic accuracy for the detection of endometrial polyps and intracavitary fibroids .
A fibroid larger than 2 cm or protruding less than 50 % into the uterine cavity (grade 2) as well as the presence of more than one lesion are known to be technically challenging for the operative hysteroscopist. Ultrasound can give valuable information improving further management planning, such as the need for sedation or anesthesia, the expected operation time, and for informing the patient about the expected procedure's success rate (one or two step procedure).
Transvaginal ultrasound assessment of the uterine cavity informs the clinician if office endometrial sampling is indicated. If the endometrium is very thin and uniform, further testing may not be necessary. If a focal intracavitary lesion is detected, an operative hysteroscopy is warranted—not office sampling. The ultrasound examination also provides valuable information to plan the operative hysteroscopy. If endometrial sampling is to be performed, the ultrasound findings will improve sample quality. Incomplete insertion of the device can be avoided and the tissue yield during sampling can be anticipated by the endometrial thickness measured at ultrasound examination. The added value of ultrasound before, during, and after endometrial sampling should be validated in future studies.
We conclude that integrating ultrasound in the diagnostic algorithm for uterine intracavitary pathology optimizes endometrial sampling and allows quality control of the sampling procedure.
Conflict of interest
Thierry Van den Bosch, Dominique Van Schoubroeck, and Dirk Timmerman declare that they have no conflict of interest.
Declaration of interest
The authors report no conflicts in interest. The authors alone are responsible for the content and writing of the paper.
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