Pipelle Endometrial Biopsy Research Articles

Transvaginal saline hysterosonography: a comparison with local anaesthetic hysteroscopy for the diagnosis of benign lesions associated with menorrhagia

The objective of this paper is to assess the diagnostic accuracy of transvaginal saline hysterosonography (TVHSg) compared to hysteroscopy in the identification of benign lesions affecting the endometrium in women with menorrhagia. A cross-sectional study was reported according to the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. These standards were introduced by an international steering committee in order to improve the reporting of diagnostic accuracy studies. The study was carried out at a one-stop menorrhagia clinic at a central teaching hospital in Newcastle Upon Tyne, UK. One hundred and forty patients were referred to the menorrhagia clinic. After clarification of their history, TVHSg was performed on each patient and the findings were recorded on a proforma. The patients then underwent hysteroscopy using local anaesthetic and a Pipelle endometrial biopsy was performed. Each operator was blinded to the findings of the preceding investigation until both proformas had been completed. The diagnostic accuracy of TVHSg was compared to hysteroscopy in the diagnosis of benign intrauterine lesions. TVHSg has a sensitivity of 0.88, a specificity of 0.99, a positive predictive value of 0.96, a negative predictive value of 0.97 and a positive likelihood ratio of 99 in the detection of endometrial polyps. For the detection of submucous fibroids, the sensitivity is 0.86, the specificity is 0.98, the positive predictive value is 0.90, the negative predictive value is 0.97 and the positive likelihood ratio is 49. We conclude that TVHSg has high diagnostic accuracy for the detection of intracavitary lesions in patients with menorrhagia when compared to out-patient hysteroscopy.

The value of frozen section Pipelle endometrial biopsy as an outpatient procedure in the diagnosis of ectopic pregnancy

SummaryThis is a prospective study evaluating 28 patients who were suspected to have ectopic pregnancy. Frozen section Pipelle endometrial biopsy was performed as an outpatient procedure to look for the presence of chorionic villi in the specimen. The sensitivity of the frozen section endometrial biopsy in detecting the presence of chorionic villi was 13.3% and the specificity was 100%. The positive predictive value was 100% and the negative predictive value was 50%. We concluded that frozen section endometrial biopsy was not helpful in predicting intrauterine gestational process; therefore, it has a limited application in patients suspected to have ectopic pregnancy.

Ultrasound examination of the endometrium before and after Pipelle endometrial sampling

To evaluate if, and to what extent, Pipelle de Cornier endometrial sampling influences the ultrasonographic features of the endometrium. This was a prospective descriptive study on 99 consecutive women in whom a Pipelle endometrial biopsy was performed. All patients first underwent a transvaginal ultrasound evaluation of the uterus. The endometrial thickness (ET) was measured and endometrial sonographic features were recorded. Thereafter, a Pipelle endometrial biopsy was taken. Finally, the ultrasound examination was repeated. The patients' characteristics, the sampling procedure, the endometrial histology and the sonographic findings before and after Pipelle biopsy were compared. Ninety-nine women, of whom 45% were postmenopausal, entered the study. The mean age was 59.0 years (SD, 9.9) for the postmenopausal women, and 41.6 years (SD, 8.7) for the rest. On histological examination, endometrial cancer was diagnosed in four patients and endometrial hyperplasia in eight patients. The average ET before Pipelle sampling was 9.0 mm (SD, 6.6) vs. 8.6 mm (SD, 7.0) after biopsy (P < 0.0001). After Pipelle sampling, the endometrium was less clearly delineated (P = 0.03) and more echogenic endometrial spots were seen (P < 0.0001). If an endometrial three-layer pattern was noted before sampling, it was not observed in most women after Pipelle biopsy (P = 0.0003). ET measurements are affected by Pipelle sampling and the quality of the ultrasound features tends to be altered by biopsy. Performing the ultrasound examination before proceeding with endometrial sampling may therefore improve diagnostic accuracy of ultrasound.

Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime

Many women are seeking alternatives to conventional forms of hormone replacement. This study evaluates the endometrial effects of natural progesterone cream used in conjunction with transdermal oestradiol. Open plan study conducted over 48 weeks. Tertiary referral London teaching hospital. Women at least two years postmenopausal. Women were recruited nationally. They applied 40 mg transdermal natural progesterone cream and 1 mg transdermal oestradiol daily. Endometrial histology, assessed by pipelle endometrial biopsy, ultrasound assessment of endometrial thickness and bleeding diaries. Fifty-four women were recruited of which 41 completed the study. Mean age was 57.4 years. Thirty-two percent of women had evidence of inadequate endometrial opposition (proliferative or hyperplastic) at the end of 48 weeks. At baseline, women had a mean endometrial thickness of 3.3 mm, which had significantly thickened to a mean of 5.3 mm by 24 weeks (P < 0.001). By 48 weeks, there was significantly greater increase in endometrial thickness from baseline in those women who displayed inadequate endometrial opposition, compared with those women who had adequate endometrial opposition (P= 0.004). At 24 weeks, 48% of women had remained entirely amenorrhoeic. By the end of the study, 35% of women had been entirely amenorrhoeic and 50% had had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time. The dose of natural progesterone cream in this study was insufficient to fully attenuate the mitogenic effect of oestrogen on the endometrium. We would not recommend this combination of hormones to be used by postmenopausal women.

OC109: Ultrasound examination of the endometrium before and after Pipelle® endometrial sampling: a preliminary prospective series

To evaluate if—and to what extent—Pipelle endometrial sampling influences the ultrasound examination of the endometrium. Prospective descriptive study on 43 consecutive women in whom a Pipelle endometrial biopsy was indicated because of abnormal uterine bleeding. All patients underwent first a transvaginal ultrasound evaluation of the uterus. The endometrial thickness (ET) was measured and the endometrial sonographic aspect was recorded. Thereafter a Pipelle endometrial biopsy was taken. Finally the ultrasound examination was repeated. The patients' characteristics, the sampling procedure and histology, and the sonographical findings before and after Pipelle biopsy were compared. Forty-three women of whom 18 postmenopausal entered the study. Mean age was 58.8 years (SD 9.3) for the menopausal women, and 40.6 years (SD 8.4) for the others. The Pipelle sampler was introduced 2.4 (SD 1.6) times in average (range 1–7). On histology endometrial cancer was diagnosed in 2 patients, atypical hyperplasia in 1, and simple endometrial hyperplasia in 2. The average ET before Pipelle sampling was 8.7 mm (SD 7.2) versus 8.5 mm (SD 7.9) after biopsy. In 14% of patients ET fell under the 5 mm threshold after Pipelle. After Pipelle sampling, the endometrium was less clearly delineated in 5 cases and the 3-layer type of the endometrium was lost in 5 women (12%). In 42% of patients echogenic endometrial spots appeared after Pipelle (in one case spots disappeared after sampling). In 9% the intracavity fluid disappeared after sampling, whereas in 21% of patients some fluid was seen in the uterine cavity after biopsy. Overall ET measurements were slightly affected by Pipelle sampling and the quality of the ultrasound features tends to be altered by biopsy. Performing the ultrasound examination before proceeding with endometrial sampling may therefore improve diagnostic accuracy of ultrasound.

Endometrial HOXA10 expression after controlled ovarian hyperstimulation with recombinant follicle-stimulating hormone

Objective To determine the effects of controlled ovarian hyperstimulation and resultant high levels of E 2 on endometrial HOXA10 expression (a marker of endometrial receptivity). Design Prospective study. Setting University academic medical center. Patient(s) Twenty-five women undergoing controlled ovarian hyperstimulation with recombinant FSH and 30 fertile controls. Intervention(s) Endometrium was obtained by Pipelle endometrial biopsy on cycle days 21–25. In addition, Ishikawa cells (a well-differentiated endometrial adenocarcinoma cell line) were treated with either E 2, recombinant FSH, GnRH agonist, or GnRH antagonist. RNA was extracted and analyzed by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). Main outcome measure(s) HOXA10 expression. Result(s) Endometrial HOXA10 expression in women undergoing controlled ovarian hyperstimulation (COH) with recombinant FSH was not different from that in fertile controls. Estradiol increased HOXA10 expression in Ishikawa cells in a dose-dependent manner from 10 −9 to 10 −7 M. Neither recombinant FSH, GnRH agonist, nor GnRH antagonist altered HOXA10 expression in these cells. Conclusion(s) Controlled ovarian hyperstimulation did not inhibit endometrial HOXA10 expression in vivo. In addition, in vitro endometrial cell HOXA10 expression was not altered by either recombinant FSH, GnRH agonist, or GnRH antagonist. COH is unlikely to adversely impact endometrial receptivity.

Randomized trial evaluating efficacy of paracervical block for pipelle endometrial biopsy

Background: Endometrial biopsy is a common gynecological office procedure, and pain perception with satisfaction are important issues. We studied the effects of paracervical block anesthesia with pipelle endometrial biopsy in a randomized-controlled trial (RCT) to identify these issues.

Usefulness of pipelle endometrial biopsy in the diagnosis of women at risk for ectopic pregnancy

Objective: The purpose of this study was to determine the accuracy of endometrial Pipelle (Unimar) biopsy to detect chorionic villi in suspected ectopic pregnancy. Study Design: This was a blinded prospective trial that involved 32 women who were in stable condition with suspected ectopic pregnancy. Endometrial pipelle sampling was performed before uterine dilation and curettage. Pipelle and frozen section results were compared with final disease. Results: Ten of 32 patients (31%) had chorionic villi that was consistent with a miscarriage; 22 of 32 patients (69%) had none detected. Pipelle biopsy had a sensitivity of 30% (95% CI, 6.7-65.2), a specificity of 100% (95% CI, 84.5-100), a positive predictive value of 100% (95% CI, 29.2-100), and a negative predictive value of 76% (95% CI, 56.5-87). Frozen section had a sensitivity of 87.5% (95% CI, 47.3-99.7), a specificity of 100% (95% CI, 83.1-100), a positive predictive value of 100% (95% CI, 59-100), and a negative predictive value of 95.3% (95% CI, 76.1-99.8). Conclusion: In patients with suspected ectopic pregnancy, Pipelle sampling is not a substitute for curettage because the sensitivity and predictive values are unacceptable.

Accuracy of Pipelle Endometrial Biopsy versus Dilation and Currettage in Patients with Endometrial Cancer

Program from the Annual Meeting of the American Radium Society: PAPERS: Sunday, April 28, 2002: 12: 40 – 1: 08 PM: LUNG AND GYN

Pipelle endometrial biopsy in the diagnosis of ectopic pregnancy

Pipelle endometrial biopsy in the diagnosis of ectopic pregnancy

A Randomised Controlled Trial Comparing Transvaginal Ultrasound, Outpatient Hysteroscopy and Endometrial Biopsy With Inpatient Hysteroscopy and Curettage

Most women with abnormal uterine bleeding are admitted to day surgery for hysteroscopy and curettage. This study was undertaken to compare this practice with one in which patients with abnormal uterine bleeding are evaluated entirely with outpatient procedures. Four hundred women with abnormal uterine bleeding were recruited from the gynecologic clinic to participate in the trial. They were randomly assigned to one of two groups. Group 1 was the inpatient group, and patients underwent examination, followed by hysteroscopy and curettage, in day surgery under light anesthesia. Group 2 patients were treated as outpatients and underwent vaginal ultrasound, followed by outpatient hysteroscopy and Pipelle endometrial biopsy. The outpatients did not have any preoperative systemic analgesia but were given a paracervical block or intracervical injections of 5 to 10 ml of 1 percent lignocaine for the procedure. The women were an average of 43 years of age. Indications for treatment were similar in both groups. Forty-one percent had menorrhagia, 31 percent had postmenopausal bleeding, 17 percent had irregular periods, and 12 percent had intermenstrual or postcoital bleeding. Hysteroscopy could not be performed in seven women in the outpatient group because the hysteroscope could not be inserted. Pipelle biopsy could be performed in five of these seven women, and all 200 underwent transvaginal sonography. The two women in whom no biopsy was performed underwent normal sonography. In each group, normal endometrium was diagnosed in one-half of patients, and fibroid tumors were found in one-fourth. Thirty-one inpatients and 26 outpatients were diagnosed with polyps, and 17 inpatients and 15 outpatients had atrophic lesions. Hyperplasia of the endometrium was found in one inpatient and two outpatients. Carcinoma was diagnosed in six inpatients and five outpatients. On hysteroscopy, four cancerous lesions were found in each group. Two carcinomas and one hyperplasia were not identified during inpatient hysteroscopy under anesthesia; in the outpatient group, one carcinoma and two hyperplasias were missed by hysteroscopy. In the outpatient group, transvaginal sonography and Pipelle sampling failed to diagnose 14 benign lesions that were seen at hysteroscopy. However, one carcinoma and two hyperplasias missed by hysteroscopy were detected with the combination of sonography and Pipelle sampling. Because of the large number of benign lesions that were identified only by hysteroscopy, the total number of pathologic abnormalities detected by hysteroscopy was significantly greater than the number diagnosed by a combination of sonography and biopsy (P = .0076). The quality of the biopsy specimens was similar in both groups. Patient satisfaction, as measured by a postprocedure questionnaire, showed that both procedures were well tolerated and accepted. Br J Obstet Gynaecol 1999;106:1259–1264

The value of outpatient hysteroscopy in the management of postmenopausal bleeding: a review of 862 cases

Objective To evaluate the efficacy, reliability and acceptability of outpatient hysteroscopy in the investigation of postmenopausal bleeding in a major teaching hospital. Design A retrospective descriptive study of 862 women referred with postmenopausal bleeding for outpatient hysteroscopy. Methods Between 1994 and 1997, 862 women were referred to the Women's Endoscopy Unit at Nottingham City Hospital for postmenopausal bleeding. Of these women, 171 were receiving hormone replacement treatment. The endocervical canal and the endometrial cavity were assessed using either a 4-mm rigid or a 3.5-mm flexible hysteroscope according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Pipelle endometrial biopsy was taken when indicated. Results The mean age of patients referred with postmenopausal bleeding was 58 years. Hysteroscopy was completed successfully in 97.2% of all patients. Cervical stenosis and pain were the main reasons for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in one-third of all patients undergoing hysteroscopy. Intrauterine polyps were the commonest finding (13.9%) while submucous fibroids were detected in 10.7%. Endometrial biopsies were taken in 34.7%. Abnormal histological findings were reported in 28 cases, including eight instances of endometrial adenocarcinoma. After hysteroscopic assessment, 81% of patients were discharged while further surgical treatment was warranted in 14.6%. Conclusion Outpatient hysteroscopy is a reliable, safe and well-tolerated diagnostic procedure for investigating endometrial and endocervical pathology in patients with postmenopausal bleeding. Whenever hysteroscopic findings appear suspicious an endometrial biopsy should be taken to exclude endometrial pathology.

Anesthetic efficacy of intrauterine lidocaine for endometrial biopsy: a randomized double-masked trial

Objective: To determine the efficacy of intrauterine lidocaine for decreasing pain associated with endometrial biopsy using the Pipelle instrument (Unimar; Wilton, CT). Methods: Forty-one premenopausal and postmenopausal women had 5 mL of either 2% lidocaine or saline instilled in their uteri before endometrial biopsies. Subsequently, each woman completed a 20-cm visual analogue scale for subjective pain experience. We compared histologic findings in endometrial specimens. Results: Before the study, analysis of specimens ( n = 6) found no histologic effect on ability to interpret endometrial biopsies by pathologists who were masked to lidocaine or saline. There was no statistically significant difference in age, parity, race, history of chronic pelvic pain, menopausal status, use of tenaculum, or prior endometrial biopsy. The procedure was easy, with no clinically significant side effects. On the visual pain scale, the median (range) score for the lidocaine group (4.7, 0–19.7) compared with the placebo group (9.9, 1.6–20) showed significant reduction in pain corresponding with a decrease from moderate to mild ( P < .01). Conclusion: Intrauterine lidocaine is simple and effective for decreasing pain associated with the Pipelle endometrial biopsy.

The impact of introducing transvaginal sonography ± pipelle endometrial biopsy on the management of menstrual disorders

The impact of introducing transvaginal sonography ± pipelle endometrial biopsy on the management of menstrual disorders

A review of 2581 out‐patient diagnostic hysteroscopies in the management of abnormal uterine bleeding

ObjectiveTo evaluate the clinical efficacy, reliability and acceptability of out‐patient diagnostic hysteroscopy at a large teaching hospital.SettingThe Women's Endoscopy Unit at Nottingham City Hospital, Nottingham, UK.SubjectsBetween 1994 and 1997, 2581 women were referred for menstrual problems and abnormal uterine bleeding. The endocervical canal and endometrial cavity were assessed using either a 4‐mm rigid or a 3.5‐mm flexible hysteroscope, according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Endometrial biopsy was taken when indicated.ResultsThe main indications for referral for diagnostic hysteroscopy included menorrhagia (37.5%), postmenopausal bleeding (33.4%), intermenstrual bleeding (26.7%) and metrorrhagia (8.8%). Less common indications included treatment with tamoxifen, review of previous endometrial pathology or abnormal glandular cells on cervical cytology, and investigation for infertility. The mean age of patients referred was 49.3 years. Hysteroscopy was completed successfully in 96.8% of all patients, with pain being the main reason for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in 34% of all patients. Submucous fibroids were the commonest cause of intrauterine pathology (11.4%) with the highest incidence found in women referred for menometrorrhagia (17.2%). Endometrial polyps were detected in 10.6% of all the patients. The endometrium was characterized by the hysteroscopist as atrophic, thickened, polypoid, haemorrhagic or malignant. Endometrial Pipelle biopsies were taken in 48.6% of all cases. Abnormal histological findings were reported in 61 cases including 11 instances of endometrial adenocarcinoma. The concordance rate between hysteroscopic and histological findings for all abnormalities was 63.9%. Further medical treatment was offered to 406 patients (16.3%), while 185 patients (17.3%) needed additional surgery as in‐patients.ConclusionOut‐patient hysteroscopy is a safe, acceptable and well‐tolerated procedure that provides useful information about the uterine cavity. Endometrial biopsy improves the diagnostic accuracy of hysteroscopy in detecting endometrial pathology.

The association of asymptomatic bacterial vaginosis with upper genital tract infection

Objective: To determine whether asymptomatic bacterial vaginosis (BV) is associated with upper genital tract inflammation or bacterial colonization. Methods: Fifty nonpregnant women with intact uteri who planned to undergo gynecologic surgery and had no recent symptoms of vaginal infection were enrolled. We obtained a vaginal swab for Gram stain, endocervical swab for chlamydia and gonorrhea DNA probe testing, and Pipelle endometrial biopsy for aerobic and anaerobic cultures and histology. We correlated surgical findings and histology of available surgical specimens with the microbiologic results. The diagnosis of BV was made according to Speigel’s criteria. Bacteria isolated from the uterus were classified as high virulence versus low virulence. Contingency tables were analyzed using the chi-square or Fisher Exact tests. Results: Twenty-one of 50 patients had BV on Gram stain, 3 had intermediate BV, and 3 had unreadable slides. Eleven patients had histologic endometritis, including 7 of the 21 with BV. The association between BV and endometritis was not statistically significant. Thirty-eight patients had a positive endometrial culture; 18 of these also had BV and 3 had intermediate BV. Of patients with a positive endometrial culture, isolates from those who also had BV or intermediate BV were more likely to be highly virulent pathogens compared to those who tested negative for BV ( P < .05). No patients had positive gonorrhea or chlamydia tests. Of the 37 patients who underwent abdominal surgery, 20 had visible adhesions. The association between adhesions and endometritis, BV, or positive endometrial cultures was not significant. Conclusion: Patients with asymptomatic BV are more likely than patients without BV to have highly virulent bacteria isolated from the endometrium. BV may predispose to upper genital tract infection.

Evaluation of a one-stop clinic for the rapid assessment of post-menopausal bleeding

Summary In this study, we evaluated the management of postmenopausal bleeding at our one-stop clinic where the first line investigations were a transvaginal ultrasound scan and a pipelle endometrial biopsy. The records of 212 women seen in this clinic in 1994 were reviewed. One hundred and forty-four women (67.9%) were evaluated and reassured in one visit. The mean waiting period following referral to the clinic by the general practitioner was 36 days (range 6-157 days), and only 45 women (21%) required a hysteroscopy. The commonest diagnosis made was endometrial atrophy or no significant endometrial pathology (130 women (61.3%). Endometrial cancer was diagnosed in 12 women (5.6%), and one case of previously unsuspected ovarian cancer was detected. Our findings show that most women with post-menopausal bleeding can be assessed in one visit, and hysteroscopy is not always necessary in the initial assessment of this complaint.

How representative are Pipelle endometrial biopsies? A retrospective analysis of 324 biopsies followed by transcervical resection of the endometrium or hysterectomy

ObjectiveTo evaluate the diagnostic accuracy of Pipelle endometrial biopsies before surgical treatment of uterine bleeding disorders.DesignRetrospective analysis.SettingCounty Hospital unit specializing in operative hysteroscopy.InterventionsRoutine outpatient endometrium biopsies were taken from 628 patients because of uterine bleeding disorders. Of these patients, 249 underwent transcervical resection of the endometrium (TCRE) and 75 had a hysterectomy within 6 months.ResultsComparing the two subgroups ‘malignant’ and ‘benign’, the positive predictive value for endometrial malignancy was 100% (95% CI, 73.5–100). Insufficient tissue was obtained in five cases (1.5%); in three there were submucous fibroids, in one sampling took place after TCRE, and one patient had atrophic endometrium.ConclusionAdequate preoperative histological assessment of the endometrium is feasible with Pipelle biopsies, and they are highly accurate in detecting endometrial malignancy.

Comparison of cytospat and pipelle endometrial biopsy instruments

Objective: To compare two endometrial biopsy techniques, based on the quality of material obtained, cost effectiveness, and pain during the procedure. Study design: A single blind, randomized prospective study. Results: A total of 365 women with peri/postmenopausal bleeding were randomized into two groups: 174 biopsied with cytospat (C) and 191 biopsied with pipelle (P). Both procedures were then followed by either dilatation and curettage (D&C) or hysterectomy. Pain was evaluated in 379 patients, with the result being better tolerance for P vs. C (3.55 vs. 4.06, P = 0.07). With C, the sensitivity in histological evaluation was 82% for benign endometrium, 60% for endometrial hyperplasia and 60% for corpus uterine neoplasia as compared to the D&C and hysterectomy material. With P the sensitivity was 84, 71 and 60%, respectively for the three diagnoses, as compared to the D&C and hysterectomy material. Insufficient tissue for pathologic evaluation was present in 24% of C, 25% of P and 9.8% of D&C samples. Conclusions: Cost effectiveness for pipelle is slightly higher than for Cytospat.

Transvaginal ultrasound measurement of endometrial thickness and endometrial pipelle sampling as an alternative diagnostic procedure to hysteroscopy and dilatation and curettage in the management of post-menopausal bleeding

Summary In order to evaluate pipelle endometrial sampling combined with ultrasound measurement of endometrial thickness as an initial diagnostic procedure in the assessment of endometrial pathology in patients presenting with postmenopausal bleeding, 50 consecutive patients were studied prospectively. In each patient measurement of endometrial thickness and pipelle endometrial biopsy were performed as an out-patient procedure before hysteroscopy and dilatation and curettage (D&C). The diagnostic sensitivity with pipelle endometrial sampling alone in detecting endometrial pathology was 25% with a specificity of 100%. The measurement of endometrial thickness had a sensitivity of 62% with a specificity of 87.8%. Pipelle sampling combined with endometrial thickness increased the sensitivity to 87.5% with a specificity of 87.8%. Therefore, we suggest that pipelle sampling combined with sonographic measurement of endometrial thickness is an acceptable, less invasive alternative to hysteroscopy and D&C as a first-line investigation in the management of post-menopausal bleeding.