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.
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.
- Cornier E (1984) The Pipelle: a disposable device for endometrial biopsy. Am J Obstet Gynecol 148:109–110PubMedView ArticleGoogle Scholar
- Kaunitz AM, Masciello A, Ostrowski M, Rovira EZ (1988) Comparison of endometrial biopsy with the endometrial Pipelle and Vabra aspirator. J Reprod Med 33:427–431PubMedGoogle Scholar
- Hill GA, Herbert CM 3rd, Parker RA, Wentz AC (1989) Comparison of late luteal phase endometrial biopsies using the Novak curette or PIPELLE endometrial suction curette. Obstet Gynecol 73:443–445PubMedGoogle Scholar
- Stovall TG, Photopulos GJ, Poston WM, Ling FW, Sandles LG (1991) Pipelle endometrial sampling in patients with known endometrial carcinoma. Obstet Gynecol 77:954–956PubMedGoogle Scholar
- Rodriguez GC, Yaqub N, King ME (1993) A comparison of the Pipelle device and the Vabra aspirator as measured by endometrial denudation in hysterectomy specimens: the Pipelle device samples significantly less of the endometrial surface than the Vabra aspirator. Am J Obstet Gynecol 168:55–59PubMedView ArticleGoogle Scholar
- Clark TJ, Mann CH, Shah HM, Khan KS, Song F, Gupta JK (2002) Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial cancer: a systematic quantitative review. BJOG 109:313–321PubMedView ArticleGoogle Scholar
- Van den Bosch T, Cornelis A (1998) Endometrial malignancy missed by office sampling. Aust N Z J Obstet Gynaecol 38:1–2View ArticleGoogle Scholar
- Van den Bosch T, Vandendael A, Van Schoubroeck D, Wranz PAB, Lombard CJ (1995) Combining vaginal ultrasonography and office endometrial sampling in the diagnosis of endometrial disease in postmenopausal women. Obstet Gynecol 85:349–352PubMedView ArticleGoogle Scholar
- Van den Bosch T, Van Schoubroeck D, Vergote I, Moerman P, Amant F, Timmerman D (2007) A thin and regular endometrium on ultrasound is very unlikely in patients with endometrial malignancy. Ultrasound Obstet Gynecol 29:674–679PubMedView ArticleGoogle Scholar
- Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, Brand R, Gracy D (1998) Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 280:1510–1517PubMedView ArticleGoogle Scholar
- Tabor A, Watt HC, Wald NJ (2002) Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol 99:663–670PubMedView ArticleGoogle Scholar
- Timmermans A, Opmeer B, Khan K, Bachmann LM, Epstein E, Clark JT, Gupta JK, Bakour SH, Van den Bosch T, van Doorn HC, Cameron ST, Giusa MG, Dessole S, Dijkhuizen FPHLJ, ter Riet G, Mol WJ (2010) Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis. Obstet Gynecol 116:160–167PubMedView ArticleGoogle Scholar
- Leone F, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein SR, Marret H, Parsons AK, Gull B, Istre O, Sepulveda W, Ferrazzi E, Van den Bosch T (2010) Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol 35:103–112PubMedView ArticleGoogle Scholar
- Van den Bosch T, Van Schoubroeck D, Van Calster B, Cornelis A, Timmerman D (2012) Pre-sampling ultrasound evaluation and assessment of the tissue yield during sampling improves the diagnostic reliability of office endometrial biopsy. J Obstet Gynaecol 32:173–176PubMedView ArticleGoogle Scholar
- Van den Bosch T, Van Schoubroeck D, Timmerman D (2005) Ultrasound examination of the endometrium before and after Pipelle® endometrial sampling. Ultrasound Obstet Gynecol 26:283–286PubMedView ArticleGoogle Scholar
- Werbrouck E, Veldman J, Luts J, Van Huffel S, Van Schoubroeck D, Timmerman D, Van den Bosch T (2011) Detection of endometrial pathology using saline infusion sonography versus gel instillation sonography: a prospective cohort study. Fertil Steril 95:285–288PubMedView ArticleGoogle Scholar
- de Kroon C, De Bock GH, Dieben SWM, Jansen FW (2003) Saline contrast hydrosonography in abnormal uterine bleeding: a systematic review and metaanalysis. BJOG 110:938–947PubMedView ArticleGoogle Scholar
- Wamsteker K, Emanuel MH, de Kruif JH (1993) Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 82:736–740PubMedGoogle Scholar
- Emanuel MH, Wamsteker K, Hart AA, Metz G, Lammes FB (1999) Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol 93:743–748PubMedView ArticleGoogle Scholar
- Cravello L, Agostini A, Beerli M, Roger V, Bretelle F, Blanc B (2004) Results of hysteroscopic myomectomy. Gynecol Obstet Fertil 32:825–828, Article in FrenchPubMedView ArticleGoogle Scholar
- Marret H, Cottier JP, Alonso AM, Giraudeau B, Body G, Herbreteau D (2005) Predictive factors for fibroids recurrence after uterine artery embolisation. BJOG 112:461–465PubMedView ArticleGoogle Scholar
- Di Spiezio SA, Mazzon I, Bramante S, Bettocchi S, Bifulco G, Guida M, Nappi C (2008) Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 14:101–119View ArticleGoogle Scholar
- Rovio PH, Helin R, Heinonen PK (2009) Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia. Arch Gynecol Obstet 279:159–163PubMedView ArticleGoogle Scholar
- Camanni M, Bonino L, Delpiano EM, Ferrero B, Migliaretti G, Deltetto F (2010) Hysteroscopic management of large symptomatic submucous uterine myomas. J Minim Invasive Gynecol 17:59–65PubMedView ArticleGoogle Scholar
- Lasmar RB, Xinmei Z, Indman PD, Celeste RK, Di Spiezio SA (2011) Feasibility of a new system of classification of submucous myomas: a multicenter study. Fertil Steril 95:2073–2077PubMedView ArticleGoogle Scholar