Endometrial sampling: When? Where? Why? With what?

Today, evaluating women with abnormal uterine bleeding generally is initiated in the office with an endometrial biopsy. The indications and contraindications for endometrial sampling along with situations which do not, per se, demand sampling are listed in Figure 1. In women younger than 40 years of age, it may be appropriate in some clinical situations to initiate hormonal therapy after an endocrine evaluation before endometrial sampling; however, with the newer sampling devices that cause minimal discomfort, a histologic evaluation can be performed easily. Furthermore, the endometrial biopsy may help to distinguish anovulatory from ovulatory bleeding and exclude a hyperplastic condition or carcinoma. If the patient does not respond to medical therapy, then hysteroscopy may identify endometrial polyps or submucosal myomas. Bleeding in postmenopausal women requires endometrial sampling. If a diagnosis of cancer can be made in the office, this will expedite treatment. For those cases in which, for technical reasons, it is impossible to do an office biopsy or in which an examination under anesthesia is necessary for evaluation, then a D&C is indicated. The refined technology of transvaginal ultrasonography and hysteroscopy in the future may influence more directly the evaluation of women with abnormal uterine bleeding. As noted, transvaginal ultrasonography may determine which women would benefit from an endometrial biopsy, both for symptomatic and asymptomatic women. Likewise, the hysteroscope, under certain circumstances, may help identify pathologic findings missed by endometrial biopsy and/or reassure the patient or physician that a negative biopsy is the result of an atrophic mucosa. Because of the increase in the use of hormonal therapy, both in postmenopausal women for replacement and in women with breast cancer as adjuvant therapy, endometrial sampling must be performed for screening. Follow-up for women with premalignant changes of the endometrium treated with hormones also would require sampling to assess response. The overwhelming arguments in favor of the accuracy of an office-based endometrial biopsy, the convenience to the patient and physician, and the cost containment have been established firmly in the literature. Office screening procedures will continue to play important roles in the diagnostic skills of the gynecologist.