Procedure: Endometrial Aspiration Biopsy

Endometrial biopsies are performed to sample tissue from the endometrium to rule out suspected endometrial cancer in the setting of abnormal uterine bleeding. Although not a first-line investigation in a patient who presents with vaginal bleeding without risk factors for endometrial cancer, it is always a first-line investigation in a postmenopausal woman with abnormal uterine bleeding. The procedure can be done in the office, and often is done after transvaginal ultrasound to assess thickness and character of the endometrial lining. The only absolute contraindications are current pregnancy or a bleeding diathesis. Although I haven't yet seen one been doing ever in real-life yet, let alone having had the opportunity to try my hand at this procedure, we did have a clinical skills training day where we got to practice performing endometrial aspiration biopsies on kiwis... Apparently that's what it's like. I personally think doing it on a young coconut would be a better analogy, based on my understanding of what the texture of the endometrial lining must be like, but alas  we don't live in Southeast Asia.

Equipment

1. Large vaginal speculum
2. Nonsterile gloves, gown, mask, and eye protection
3. Antiseptic solution
4. Cotton balls
5. Ring forceps
6. Uterine sound
7. Single-toothed tenaculum
8. Topical benzocaine gel (20%) or benzocaine spray
9. Buffered formalin specimen containers with patient identification labels (two)
10. Endometrial Aspirator 

Procedure

1. Ensure Pap is up to date. If not, obtain Pap smear before performing the endometrial biopsy.
2. Obtain consent (indication/risks/alternative options, ensure understanding and answer any questions) *Risks: Uterine perforation, excess uterine bleeding, false negative from missing areas with pathology, vasovagal response and/or pain immediately post-procedure, infection
3. Optional: The patient may take an NSAID 30-60 min prior to the procedure to decrease cramping/pain from the procedure.
4. Timing of the procedure: Best to be done when there is no active bleeding, if possible.
5. Positioning: Position the patient in dorsal lithotomy.
6. Don gloves, gown, mask, and eye protection (universal precautions)
7. Perform a a bimanual exam to determine orientation and size of uterus
8. Insert large speculum. Visualize the cervix and clean off any mucus or debris using antiseptic solution, cotton balls, and ring forceps. 
9. Use the uterine sound to dilate the cervical os
10. Proceed with endometrial biopsy. Technique will depend on endometrial biopsy instrument. Avoid contaminating instrument by touching vaginal side walls. Generally insert tip of instrument to uterine fundus and create suction, drawing up endometrial tissue. Continue to move catheter about the uterus, sampling circumferentially from a variety of areas. Enough sample is acquired when about half of the catheter is filled with endometrial tissue.
11. After the procedure is done, the patient should remain supine for 10 minutes.
12. Advise patients to return for assessment if they develop fever, bleeding heavier than a normal period, or cramping >48 hours after the procedure (the patient may take NSAIDs to manage cramping/discomfort in the first 48 hours).
13. Document the procedure.