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Endometrial biopsy is a simple and effective office-based procedure that samples the endometrium to allow for direct histological evaluation. A clinician in the outpatient setting can perform this procedure independently. Endometrial biopsy is often used to evaluate abnormal uterine bleeding. It is a relatively quick and cost-effective way to sample the endometrium. It is an essential skill to have as endometrial cancer is a common cancer among women. This activity describes when and how to perform an endometrial biopsy and highlights interprofessional team members' role in collaborating to provide well-coordinated care and enhance outcomes for patients undergoing this procedure. Objectives: Review the indications for endometrial biopsy. Describe the steps involved in performing an endometrial biopsy. Summarize the most common complications of an endometrial biopsy. Explain the importance of collaboration and communication amongst the interprofessional team to ensure appropriate management of endometrial biopsy results, ensure that patients receive appropriate follow-up care, and improve patient outcomes. Access free multiple choice questions on this topic.

Endometrial biopsy is frequently used to evaluate abnormal uterine bleeding. It is a relatively quick and cost-effective way to sample the endometrium to allow for direct histological evaluation of the endometrium. It is an essential skill to have as endometrial cancer is the fourth most common cancer among women. The American Cancer Society estimates there will be 65,950 new uterine cancer cases and 12,550 related deaths in 2022 [American Cancer Society. Facts & Figures, 2022]. The patient does not need to undergo more invasive procedures as endometrial biopsies have a high sensitivity and specificity for detecting endometrial hyperplasia and endometrial malignancy, equal to the diagnostic accuracy of dilatation and curettage (D&C) procedure.[1]

The most common side effect of an endometrial biopsy is cramping. This can be significantly reduced with the administration of pre-procedure NSAIDs. Once the procedure is completed, women may report light vaginal bleeding or spotting for several days. Less common side effects include uterine perforation, pelvic infection, and bacteremia. They are monitored by instructing the patient with strict return precautions, including returning to the office for fever, cramping for more than 48 hours, increasing pain, bleeding heavier than a normal menstrual period, or any foul-smelling discharge.

The female patient should be educated by the gynecologist, primary care provider, and gynecology nurse that endometrial biopsy is a procedure that, without debate, has clinical importance when evaluating abnormal uterine bleeding or postmenopausal bleeding. This education is part of the collaborative, interprofessional healthcare team approach to preparing for and performing this procedure. However, there is currently a debate on whether an endometrial biopsy should be used to evaluate infertility. Chronic endometritis is a bacterial infection of the endometrium that causes an increased prevalence of immune cells in the endometrium, and this change in histology can adversely affect fertility. There is a prevailing opinion that because chronic endometriosis is often asymptomatic, it can only be diagnosed through an endometrial biopsy. Therefore endometrial biopsy should be performed in the evaluation of infertility.[7] [Level 1] However, the American Society for Reproductive Medicine and the Choosing Wisely Campaign recommend against endometrial biopsy in evaluating infertility. They cite evidence that the endometrium's histological dating does not determine infertility, and the presence of chronic endometritis does not affect the cumulative live birth rate.[8][9] [Level 1] For abnormal uterine bleeding, the American College of Obstetricians and Gynecologists support recommendations that include differences in the indications for endometrial sampling in women based on age. In women younger than forty-five, an endometrial biopsy is only indicated if abnormal uterine is persistent. Endometrial biopsy should also be considered if there is a history of unopposed estrogen exposure, failed medical, or women at high risk of endometrial cancer. Any abnormal uterine bleeding in women over the age of forty-five should include an endometrial biopsy in the diagnostic workup.

For abnormal uterine bleeding, the American College of Obstetricians and Gynecologists support recommendations that include differences in the indications for endometrial sampling in women based on age. In women younger than forty-five, an endometrial biopsy is only indicated if abnormal uterine is persistent. Endometrial biopsy should also be considered if there is a history of unopposed estrogen exposure, failed medical, or women at high risk of endometrial cancer. Any abnormal uterine bleeding in women over the age of forty-five should include an endometrial biopsy in the diagnostic workup. There is another special subset of pre and postmenopausal women in whom the American College of Obstetricians and Gynecologists provide specific guidance in their recommendations for endometrial biopsy. This includes women who are on tamoxifen therapy. An endometrial biopsy should be performed for all postmenopausal patients on tamoxifen therapy who have abnormal uterine bleeding. It is common for premenopausal women to experience menstrual irregularities, most commonly amenorrhea, while taking tamoxifen. The guidelines do not suggest routine endometrial biopsy in these women. Unless there are risk factors for endometrial cancer, premenopausal women treated with tamoxifen do not require any additional screening or workup beyond routine gynecologic care.[10]