Endometrial biopsy is the surgery of removing a small piece of tissue from the overgrowing endometrial lining in the uterus. The sample helps to identify the endometrial thickness and presence of cancerous cells. Endometrial biopsy is required in chronic anovulation, uterine cancer, and woman infertility.

The endometrium adequately fulfills a key role in the female reproductive system. It is furthermore known as a major part of the reproductive organ 'uterus'. Endometrial lining majorly produces key hormones in the menstrual cycle. This also provides nutrition to the developing embryo during pregnancy. The tissue, which builds a woman's endometrial lining, serves as an internal wallpaper of the uterus. A uterus is a pear-shaped organ of the woman's body, which provides space for an unborn baby to develop for nine months. In rare cases, the endometrium undergoes several abnormalities like endometriosis, hyperplasia, and cancer. Endometrium promptly follows a natural flow in the menstruation cycle. However, if this particular flow is disturbed, then endometrial abnormalities commence in the concerned individual. Doctors traditionally perform some of the quality and effective medical tests to examine such conditions and identify the root cause behind unusual endometrial conditions. One of the important and preferred medical tests includes an endometrial biopsy. Endometrial biopsy indications generate when an endometrial thickness increases and the cells start growing abundantly outside its specified space. In this case, the lining of endometrial continues to build upon ovaries, fallopian tubes, and lining of the pelvis in the woman. Unwanted growth of the endometrial lining in uterus hinders the continuous process of menstruation and pregnancy. It also leads to the cysts (endometriomas) made up inside the ovaries, scar tissues, and adhesions. A few other abnormalities identified through endometrial biopsy are endometrial hyperplasia caused due to perimenopause and most crucial endometrial cancer. (1)

In this article, you will get to know about the following:

Following is the deep analysis and explanations of the above questions. We have also tried to cover the maximum number of aspects related to the endometrial biopsy:

What is Endometrial Biopsy?

Endometrial Biopsy includes the process of removing a small tissue piece from a normal endometrial thickness range. Primarily, a sample of an overgrown tissue from the endometrial lining of the uterus is taken out to examine further with the assistance of a medical specialist. A sample of the tissue can show the formation and changes in the working of the cells present in the endometrium. This change in normal endometrial thickness range takes place due to the abnormal build-up of the tissue and hormonal variations. The sample of an endometrial tissue also defines certain other conditions in the body, like uterine infection (endometritis). The endometrial biopsy is normally performed without any use of anesthesia in a clinic. Doctors typically take 10 minutes to perform the biopsy session with ease which depends on the expertise of the doctor. (2) (3)





An expert pathologist performs the examination of the sample under the microscope. Performing other required medical tests may only suggest for the occurrence of cancer, but a biopsy of the exact tissue precisely helps in specifying the presence of cancer. A pathologist is a specialist doctor who only performs and interprets laboratory samples. The doctor also performs an evaluation of cells, tissues, and organs to diagnose accurate disease. A doctor performs the biopsy test with a very thin tube, which extracts a small sample from the uterus to test for a specific condition. A patient encounters endometrial biopsy pain, bleeding, and cramps during and sometimes after the process. The symptoms which are seen in the patient are similar to women menses. Usually, these common and minor symptoms cure in a short period of time. One may also consume a Non-Steroidal Anti-Inflammatory Drug (NSAID) as prescribed by her doctor to reduce endometrial biopsy pain. Endometrial biopsy proves to be an accurate and effective test to diagnose uterine cancer and cause of normal endometrial thickness range. Women suffering from vaginal bleeding prior to the test require a subsequent test with dilation and curettage (D&C). This advanced procedure is substantially needed if abnormal cells are undetected during a biopsy. D&C is another similar but more prominent procedure to remove a tissue sample from the uterus. It is a more painful process, so anesthesia is considered mandatory during the procedure.

Endometrial biopsy indications and its uses:

A woman with a below-mentioned indication needs to obtain an endometrial biopsy, especially when she is not pregnant:



Chronic anovulation: A woman whose ovaries are not releasing eggs regularly similar to Polycystic Ovary Syndrome (PCOS). Usually, these women are at elevated risk for endometrial problems in terms of size as well. Undergoing an endometrial biopsy helps in assessing their endometrial lining thickness of the uterus. In fact, the biopsy also ensures that the patient is not suffering from any severe diseases like endometrial hyperplasia or cancer.

A woman whose ovaries are not releasing eggs regularly similar to Polycystic Ovary Syndrome (PCOS). Usually, these women are at elevated risk for endometrial problems in terms of size as well. Undergoing an endometrial biopsy helps in assessing their endometrial lining thickness of the uterus. In fact, the biopsy also ensures that the patient is not suffering from any severe diseases like endometrial hyperplasia or cancer. Abnormal vaginal bleeding: Endometrial biopsy helps in confirming the presence of an abnormality in the lining of the endometrial like endometrial hyperplasia or cancer.

Endometrial biopsy helps in confirming the presence of an abnormality in the lining of the endometrial like endometrial hyperplasia or cancer. Uterine Cancer: If a woman suspects to have uterine cancer, then the biopsy plays a key role in identifying the location of cancer cells in the uterus of a woman. These cancer cells are usually present in the endometrium or the cervix region of the uterus.

If a woman suspects to have uterine cancer, then the biopsy plays a key role in identifying the location of cancer cells in the uterus of a woman. These cancer cells are usually present in the endometrium or the cervix region of the uterus. Woman infertility: Performing a biopsy on time also confirms when the woman had her last ovulation cycle. However, the same can also be checked through a regular blood test of the progesterone level. (4)

Contraindications while performing Endometrial Biopsy:

Below we are mentioning some reasons where patients are not advised to go for endometrial biopsy:





Prolonged Vaginal bleeding

Pregnancy

Infection

Presence of Perforation in uterus or cervix

Minor spotting and mild cramping

Fever or chills

Severe lower belly pain

Details of the above-mentioned points are explained below (5):

Prolonged Vaginal Bleeding: Subsequently, a patient suffers vaginal bleeding due to the surgery for another few days. The bleeding is common, and one may also use a pad or consume medication to relief bleeding. In case, one is suffering from heavy bleeding then, she should immediately contact the doctor.

Subsequently, a patient suffers vaginal bleeding due to the surgery for another few days. The bleeding is common, and one may also use a pad or consume medication to relief bleeding. In case, one is suffering from heavy bleeding then, she should immediately contact the doctor. Pregnancy: The procedure is strictly prevented during pregnancy as it harms a child and significantly damages the proper progression of the pregnancy. Therefore, it is advisable to promptly inform the doctor about the pregnancy before beginning with the biopsy.

The procedure is strictly prevented during pregnancy as it harms a child and significantly damages the proper progression of the pregnancy. Therefore, it is advisable to promptly inform the doctor about the pregnancy before beginning with the biopsy. Infection: Due to the usage of various medical instruments, a patient may attain vaginal infection. Usually, the case is rare when a patient attracts an infection after undergoing endometrial biopsy, but precautions should be kept in mind before commencing with the treatment.

Due to the usage of various medical instruments, a patient may attain vaginal infection. Usually, the case is rare when a patient attracts an infection after undergoing endometrial biopsy, but precautions should be kept in mind before commencing with the treatment. Presence of perforation in uterus or cervix : There is another rare condition when a hole forms in the wall of the uterus due to a thin plastic catheter in the instrument. This usually happens when the uterus's angle positions from up to down.

: There is another rare condition when a hole forms in the wall of the uterus due to a thin plastic catheter in the instrument. This usually happens when the uterus's angle positions from up to down. Foul-smelling drainage from your vagina: A patient will experience cramps and spotting of blood along with mucus for some days after the biopsy is performed. This mucus may smell bad for some days due to the interference of instruments in the vagina.

A patient will experience cramps and spotting of blood along with mucus for some days after the biopsy is performed. This mucus may smell bad for some days due to the interference of instruments in the vagina. Fever or chills: A woman gone through endometrial biopsy may suffer weakness, minor fever, and chills as a common side effect of the biopsy.

A woman gone through endometrial biopsy may suffer weakness, minor fever, and chills as a common side effect of the biopsy. Severe lower belly pain: The procedure depends upon removing a small tissue sample from the endometrial lining of the uterus. Any minor cut or surgery in uterus normally takes a few days to get healed depending on the manner it is dealt with. It may even evolve severe pain in the abdominal while curing. Similarly, in an endometrial biopsy, the rigorous or severe pain generates for some time. Therefore, one should strictly follow the medication prescription to ensure that timely cure occurs without severing of the condition.

The severity of endometrial biopsy pain and recovery time:

It is necessary to inform the patient about the severity of the endometrial biopsy pain so that she can prepare for the same. The surgery, which is performed for the biopsy enhances the degree of pain and uneasiness in some of the patients. Sometimes, the patient feels sick and requires bed rest for the next 1-2 days. However, medicinal drugs available at a normal drug store help in bearing the continual pain. But before a patient intakes medication, he must consult her doctor. Along with medication, the patient should also avoid doing stressful work and vigorous exercise. It is seen in some rare cases that the psychology of a woman also impacts due to severe continuous pain. An endometrial biopsy causing excruciating pain also influences the ability to conceive negatively. It practically takes one week to get properly recovered from the side effects of the endometrial biopsy. During this time span, one should avoid any type of insertion into the vagina like a tampon and abstain from performing intercourse.

Significance of Endometrial Biopsy Test:

Endometrial biopsy assists a doctor in effectively finding out the unknown and actual cause of heavy or irregular bleeding. It also proves to be one of the major and common medical procedures to accurately identify and help in confirming the presence of endometrial cancer in the patient. Although the endometrial tests are held in a conventional clinic or in a hospital, an exceptionally skilled and expert doctor is required to perform such a complicated and important medical tests. The endometrial biopsy also assists the doctor in precisely identifying the hormonal levels associated with endometrium lining and subsequent changes in the viable cells of the endometrial lining of the uterus.

Common Symptoms of Endometrial Thickness:

Endometrial hyperplasia refers to a condition when the endometrium or its lining inside the uterus, becomes thicker than the normal thickness. The thickness of the endometrial lining contributes to the occurrence of cysts and unusual bleeding. However, in rare cases, untreated and ignored symptoms of abnormalities of endometrial lining evolve into uterus cancer. Usually, the endometrial hyperplasia occurs due to excessive estrogen in the body without progesterone. The ovulation is restricted when progesterone does not rise and shedding of the endometrial lining does not occur. The endometrium lining continues to thicken in a positive response towards estrogen. The cells of endometrial lining club-together and make it abnormal. This condition rarely leads to cancer in a woman. Hyperplasia mostly occurs in menopausal and perimenopausal conditions, when ovulation does not occur, and the formation of progesterone levels becomes extinct.

A common, yet most prominent reasons and symptoms of having an irregular or abnormal endometrial lining is abnormal bleeding through the uterus. One must contact the doctor in case any following symptoms are found: (8) (9)

Heavy and prolonged bleeding than usual periods.

Menstruation cycle, which occurs in a shorter span of time (21 days).

Any bleeding from the uterus after the menopausal phase

Preparations need to be done before Endometrial Biopsy:

Here are some of the essential and important preparation one must follow before going for the endometrial biopsy test (10):





A health care provider must listen to and clear out all the doubts of a patient before a biopsy.

Before performing the procedure, a consent form will be given to the patient to seek his permission and awareness about the procedure. This permits the doctor to perform the procedure. It is advised to read the form thoroughly and clear all doubts right away from the health care team.

Usually, one does not need to take any specific measures before the procedure begins. Though, the physician may recommend the patient to have an effective pain reliever at least half an hour before the procedure.

If one is pregnant or believes to have symptoms creating the possibility of the same, then informing the doctor will be helpful.

One must inform the doctor about her sensitivity and allergies towards any of the items like iodine, latex, tape, or anesthesia.

Informing the doctor if the patient is already consuming regular prior prescription and herbal supplement. This will help the doctor to follow the procedure accordingly.

One must inform the doctor about the history of bleeding dysfunctions, or if there is any routine intake of blood-thinning medicines (anticoagulants). Medicines, which involves thinning of blood like aspirin, and any other medicines affecting blood clotting may hinder the body from healing. One may be told to cease the consumption of these medicines before the procedure for a certain time period.

A health care provider also asks the patient to maintain a record of her menstrual cycles. One must schedule the procedure at a particular time of her cycle after consulting the medical specialist.

If the health care provider gives the patient a sedative before beginning the procedure, then someone will be required to drive the patient home afterward. Therefore, a companion with the patient will be significant to motivate and deal with the patient's condition in a positive manner.

It is essential to bring a sanitary napkin to use it right after the procedure completes.

Based on a patient's health condition, the physician may call for additional preparation.

Materials and equipment used in biopsy:

Below are the materials, which are needed to perform endometrial biopsies (11):

Formalin Container (for specimen)

Drape

Hand gloves

Speculum for vaginal to effectively perform a uterine ultrasound

A metal container of cotton balls soaked in medicinal providing (or pre-packaged povidone swabs)

A catheter for endometrial suction

To properly grasp the cervix, a cervical tenaculum is required

Ring forceps to wipe cervix with cotton balls

Gauze (4x4s)

Cervical dilators

Anesthetic gel-like Xylocaine or spray

Scissors

The procedure of Endometrial Biopsy:

Endometrial biopsy methods vary depending on the patient's condition and her doctor's expertise. (6) (7) (12)



In routine, an endometrial biopsy follows the below-mentioned process:

The patient will be requested to undress from the region down the waist. She will then be asked to wear a comfortable hospital gown to avoid discomfort during the procedure.

The patient will be asked to empty her bladder right before performing the crucial procedure of biopsy.

A doctor will carefully insert a unique device popularly termed as a 'speculum'. The successful and smooth insertion of the speculum into the vagina will widen the walls of the vagina apart. This will precisely reveal the cervix for the procedure.

Subsequently, the cervix will be cleaned thoroughly to prevent infection. An expert doctor will only employ an antiseptic solution for the cleaning procedure.

The doctor will also numb the operational area utilizing a small and thin needle to inject vaccination, or an effective numbing spray will be applied to the patient's cervix region to anesthetize it.

A specific type of forceps, known as a 'Tenaculum', is employed to hold the cervix constant to perform a biopsy. This is the most complicated and delicate step of the endometrial biopsy. During this step, a patient will naturally proceed to feel intuitive about minor cramping. When the Tenaculum is applied precisely to the operational area one may feel minor discomfort as well.

A thin, rod-like instrument uterine sound will be carefully inserted from the cervical opening. It will reliably determine the proportional length of the uterus, normal size of endometrium in mm and its exact location for a biopsy. This procedure will also generate some cramping. The uterine sound will then be withdrawn gently.

A catheter, which typically resembles a thin tube, will be carefully inserted through the cervical opening into the uterus. A catheter includes a narrower tube known as an 'internal piston', which is present inside it. The experienced doctor will remove the inner tube instantly forming the suction at the tip of the catheter. The doctor will smoothly twist and gently move the tip of the catheter in and out to accumulate minor parts of endometrial tissue in the uterus.

A major reason for performing a biopsy decides the amount of the tissue and location of the surgery.

The doctor will gently remove the catheter and a speculum from the uterus. The tissue will be efficiently stored in a preservative safely.

The endometrial tissue will be forwarded to a specialized laboratory for functional analysis.

What happens to the sample, removed from the lining of my uterus?

The removed sample or tissue is sent to the hospital or specialized laboratory for comprehensive analysis. The descriptive analysis is performed professionally by a sub-specialist known as a pathologist. The tissue cells are carefully examined under the microscope. The pathologist is adequately skilled to perform the test and confirm if cancerous or precancerous cells are existing in the endometrium lining or not. The clinic will inform the patient with the results once the reports are available.



Endometrial lining examination becomes a must in case symptoms are getting worse and the pain becomes unbearable to handle anymore. Timely checkup can save one from pain and stress associated with the medical test. Endometrial biopsy is a very effective medical test in terms of identifying the exact cause of bleeding from the uterus. One should timely visit a doctor without keeping her health at risk and get started with the advised medical treatment.

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