Pipelle endometrial sampling in patients with known endometrial carcinoma

The purpose of this prospective clinical trial was to determine the reliability of the Pipelle endometrial biopsy instrument in recovering adequate tissue for confirmation of the diagnosis of endometrial cancer in patients with known endometrial carcinoma, and to compare endometrial histology of the sampling specimen with that of the subsequent hysterectomy specimen. Forty patients were enrolled in this study. All biopsies were performed in the office without anesthesia. The patients had a median age of 62 years (range 40-83). Discomfort was reported by the patient as mild, moderate, or severe; only two patients (5.0%) reported severe pain. There were no complications experienced with endometrial sampling. Thirty-nine of 40 specimens (97.5%) confirmed endometrial carcinoma; therefore, this study yielded a 97.5% sensitivity for the Pipelle endometrial sampling device. Comparing Pipelle and hysterectomy histology for individual patients, the histologic grade was the same in 29 (74.4%), while the Pipelle demonstrated a more advanced degree of differentiation in five (12.8%) and a lesser degree in five (12.8%). There was no residual tumor identified in one hysterectomy specimen (2.5%). Among the 12 patients who had a D&C for diagnostic purposes before referral, the Pipelle biopsy correlated with the D&C histology in ten of 12 (83.3%) and revealed a more advanced grade of tumor in one (8.3%) and a more differentiated grade in one (8.3%). In one patient, the D&C histology was adenocarcinoma grade 1, with the Pipelle demonstrating atypical hyperplasia and the hysterectomy specimen interpreted as endometrial adenocarcinoma in situ. This study demonstrates the Pipelle to be an accurate device for endometrial sampling in patients with endometrial carcinoma.     

A comparison of the Vabra aspirator and the Mimark endometrial sampler in the screening of postmenopausal women

Summary: A comparison of Vabra aspirator and Mimark endometrial sampler in postmenopausal women has shown the Mimark instrument to be significantly less painful and distressing than the Vabra and superior in terms of evaluable endometrial material obtained. Neither instrument is entirely satisfactory as a clinical screening procedure for postmenopausal women receiving hormonal replacement therapy.     

Endometrial brush biopsy for the diagnosis of endometrial cancer

OBJECTIVE: To evaluate a new technique for processing endometrial cytology for the diagnosis and exclusion of endometrial cancer. STUDY DESIGN: All women at risk for endometrial cancer with clinical indications for endometrial biopsy were evaluated by endometrial brush biopsy (Tao Brush, Cook OB-GYN, Bloomington, Indiana) and Pipelle (Cooper Surgical, Shelton, Connecticut) endometrial biopsies during one office visit. Patients were followed longitudinally for the development of endometrial cancer or until undergoing dilatation and curettage or hysterectomy. All comparisons were analyzed using the chi 2 or t test. RESULTS: One hundred one women (mean age, 58; range, 35-86) had endometrial biopsies performed. Median follow-up was > 21 months (range, 3-29). Twenty-two had cancer or atypia, while the remaining had benign diagnoses. When correlated with the final diagnosis, the Tao Brush had 95.5% sensitivity and the Pipelle, 86% sensitivity. Both devices had 100% specificity, positive predictive value of 100% and negative predictive value of 98%. When the results of the two biopsy devices are considered together, the positive and negative predictive value for detecting or excluding endometrial cancer was 100%. Based on 1998 Medicare reimbursements, a simultaneous second office biopsy using the Tao brush could save approximately $67 per case as compared to a sonohistogram and much more when compared to dilatation and curettage. CONCLUSION: Endometrial cancer can be reliably detected and excluded using these two distinct office biopsy devices simultaneously during one office visit. In patients with an indication for endometrial biopsy, no further diagnostic test may be necessary to exclude or diagnose endometrial cancer or atypia.     

A randomised trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at 'no-touch' (vaginoscopic) hysteroscopy

Objectives  To evaluate the effectiveness and tolerance of H Pipelle compared with the standard Pipelle as an endometrial biopsy device at outpatient 'no-touch' hysteroscopy.
Design  A prospective randomised trial carried out in an outpatient diagnostic hysteroscopy clinic.
Setting  A large undergraduate teaching hospital.
Population  Sixty women investigated for abnormal menstruation in an outpatient diagnostic hysteroscopy clinic.
Methods  Prospective randomised trial comparing the H Pipelle with the standard Pipelle de Cornier.
Main outcome measures  Adequacy of the biopsy specimens and women's experience.
Results  Ninety-three percent (H Pipelle) and 87% (Pipelle) of the biopsy specimens were judged to be adequate for histological diagnosis ( P > 0.05). However, obtaining endometrial sampling with the H Pipelle was significantly quicker (median times: 39 seconds [H Pipelle] and 102 seconds [Pipelle], P < 0.0001) and less painful (median visual analogue scale score: 1 [H Pipelle] and 5 [Pipelle], P = 0.011).
Conclusions  The H Pipelle not only makes it possible to perform hysteroscopy and endometrial biopsy with minimal instrumentation but is also associated with a shorter biopsy time and less discomfort than the standard Pipelle without any loss of biopsy adequacy.     

The performance of Pipelle endometrial sampling in a dedicated postmenopausal bleeding clinic.

Endometrial sampling using the Pipelle device is widely used in the UK especially in the investigation of postmenopausal bleeding. This study was aimed at evaluating the clinical benefit and diagnostic accuracy of the procedure in the setting of a dedicated one-stop clinic for women with postmenopausal bleeding. The study also examined the factors that would affect the adequacy of endometrial samples in terms of their suitability for histopathalogical examination. Data from 97 consecutive patients attending the clinic were collected and analysed. All the patients had a transvaginal ultrasound scan and an endometrial Pipelle sample was attempted unless refused by the patient. The analysis revealed that the procedure avoided the need for hysteroscopy in 61.5% of cases with an endometrial thickness of > 4mm. No cases of endometrial cancer were missed after successful Pipelle sampling. The ability to obtain an adequate endometrial sample was primarily affected by the endometrial thickness. There is only a 27% probability of getting an adequate endometrial sample in the group of women with an endometrial thickness of < 5 mm. The study recommends this procedure for the group of women with an endometrial thickness of > 4 mm. However, when the endometrial thickness is < or = 4 mm, little can be gained from endometrial sampling as malignancy is rare and the chance of getting an adequate sample is small.     

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.     

Pipelle de Cornier~子宫内膜取样器与常规诊刮进行组织学诊断的对照研究

目的:评价Pipelle de Cornier子宫内膜取样器(取样器)获取子宫内膜组织进行组织学诊断的准确性。方法:收集2011年8月至11月解放军总医院妇产科需行诊断性刮宫的245例患者,行常规诊刮前用取样器先获取子宫内膜组织。由同一病理医师进行评估并作出组织学诊断。结果:(1)刮匙法的取材失败率(7.75%)与取样器法(8.98%)比较,无显著差异(P>0.05)。取材失败者主要为绝经后病例。刮匙法与取样器法的标本满意度比较,无显著差异(P>0.05)。(2)病理诊断可对比者219例,诊断符合率93.6%(205/219)。两种取材方法在子宫内膜癌、子宫内膜单纯增生、不典型增生、子宫内膜息肉、子宫内膜炎等病变中的诊断准确率均无显著差异。8例子宫内膜癌患者,两种取材方法均无漏诊。(3)取样器取材患者疼痛感显著小于刮匙组(P<0.001)。结论:Pipelle de Cornier子宫内膜取样器能够获取满意的标本用于组织学诊断,可用于大部分需常规诊断性刮宫的病例。     

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.     

Anesthetic effect of intrauterine lidocaine plus naproxen sodium in endometrial biopsy

OBJECTIVE: To compare the efficacy of intrauterine lidocaine with oral naproxen sodium on pain perception of the patients during endometrial biopsy using the Pipelle instrument and to investigate their effects when used in combination. METHODS: One-hundred twenty women were randomly assigned to receive either 5 mL of intrauterine 2% lidocaine or saline and either 550 mg of naproxen sodium or a similar-appearing placebo tablet. Subsequently, each woman completed a 10-cm visual analog scale for subjective pain experience and a physician scored visible signs of the women's distress during the procedure using a 3-point observer scale. RESULTS: There was no statistically significant difference between the 4 groups in age, vaginal parity, history of chronic pelvic pain, menopausal status, tenaculum use, previous endometrial biopsy, or difficulty in passing the cervical os. The mean pain scores of the women in the naproxen only (5.8 +/- 2.2) and lidocaine only (5.9 +/- 2.2) groups were not significantly different compared with placebo group (7.1 +/- 2.0). However, the mean pain score in the lidocaine plus naproxen group (4.6 +/- 1.8) compared with the placebo group showed significant reduction in pain (P <.05). Pain rated by the physician was significantly lower in the lidocaine plus naproxen group compared with other groups, and a significant correlation was noted between the visual analog pain score and the patients' distress recorded by the physician (r =.791, P <.001). One patient in the naproxen-only group had vasovagal syncope after the procedure. CONCLUSION: Intrauterine lidocaine instillation significantly decreases pain associated with Pipelle endometrial biopsy when used in combination with oral naproxen sodium. LEVEL OF EVIDENCE: I     

Evaluation of the Pipelle curette for endometrial biopsy

The Pipelle endometrial suction curette was evaluated, and its application and effectiveness were compared to those of the Novak curette for endometrial sampling during the midluteal phase. Fifty women underwent an endometrial biopsy with the Pipelle and Novak curettes. Ninety percent of the women preferred the biopsy with the Pipelle. Histologically, tissue obtained with the Pipelle was satisfactory and similar to that with the Novak. The Pipelle curette appears to be an excellent device for midluteal endometrial biopsy during an infertility evaluation.     

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.

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.     

A randomized clinical trial comparing Pipelle and Tis-u-trap for endometrial biopsy

Recent publications have suggested that use of the Pipelle endometrial suction curette is a safe and effective method by which to obtain samples of endometrial tissue. To address this issue, we performed a randomized clinical trial comparing the Pipelle to the Tis-u-trap in 156 patients. The Pipelle was as effective as the Tis-u-trap in obtaining endometrial samples in both the adequacy of the specimen (Pipelle 88%, Tis-u-trap 84%) and the quality of the specimen (P = .26). This trial confirms the favorable observational reports on the use of the Pipelle for endometrial biopsy.     

Diagnosis of endometrial cancer by hysteroscopy does not increase the risk for microscopic extrauterine spread in early-stage disease

The purpose of this study was to determine whether women with endometrial cancer have a higher incidence of microscopic extrauterine spread in early-stage disease when diagnosed by hysteroscopy compared with being diagnosed by dilatation and curettage (D&C) or endometrial biopsy (Pipelle). We retrospectively reviewed the medical records of 110 patients who had undergone surgical staging for endometrial cancer from January 1997 to December 2003. They all had a preoperative histological diagnosis of endometrial carcinoma without evidence of extrauterine disease. Diagnosis was made by hysteroscopy in 64 patients (58.2%), by D&C in 17 (15.5%), and by endometrial biopsy using a Pipelle device in 29 (26.3%). The groups were compared for known prognostic factors for microscopic extrauterine spread, including age, grade, stage, and vascular space involvement, and did not differ in these parameters. Microscopic intraperitoneal disease and positive peritoneal cytology were considered the primary endpoints of this analysis. Peritoneal cytology was positive in three of 110 (2.7%) patients. The presence of positive peritoneal cytology was not associated with hysteroscopy as the diagnostic procedure. We conclude that diagnosis of endometrial cancer by hysteroscopy does not increase the risk of microscopic intraperitoneal spread compared with diagnosis by D&C or endometrial biopsy (Pipelle).     

Clomiphene citrate does not adversely affect endometrial leukemia inhibitory factor levels

The aim of this study was to compare endometrial leukemia inhibitory factor (LIF) levels in spontaneous and clomiphene citrate (CC)-induced cycles of patients with unexplained infertility. The patients were followed in two consecutive cycles. Endometrial samples were obtained 7 days after ultrasonographic evidence that ovulation has occurred during the spontaneous cycle, then the patients were induced with CC from day 5 to day 9 during the subsequent cycle with 50 mg/day, and ovulation monitoring and endometrial biopsy were performed in the same manner. The samples were obtained using a Pipelle biopsy device without using local anesthesia, and kept in formaldehyde solution until the day of measurement. Then they were homogenized in phosphate buffered distilled water, and LIF levels were detected in the homogenized fluid by ELISA method. Endometrial LIF levels were 470 ± 52 and 501 ± 45 pg/1 gram wet tissue in spontaneous and CC-induced cycles respectively, revealing no significant difference. Ovulation induction with CC did not adversely affect endometrial LIF levels.     

Clinicopathological analysis of endometrial carcinoma in young women

Endometrial carcinoma in 40 women under 40 years of age (group A), was analyzed clinicopathologically in comparison with that in 126 women over 50 years of age (group B). 1. The incidence of endometrial carcinoma in women under 40 years of age tends to increase. 2. Sixteen (41.0%) of 39 patients in group A had adenoacanthoma, while 28 (23.7%) of 118 patients in group B had it. The tumor in group A was characterized by less myometrial invasion, lower metastatic potential and coexisting endometrial hyperplasia than that in group B. 3. In group A, patients having ovaries with corpus luteum were characterized by less coexisting endometrial hyperplasia and more myometrial invasion than patients having ovaries without corpus luteum.     

Clomiphene citrate does not adversely affect endometrial leukemia inhibitory factor levels.

The aim of this study was to compare endometrial leukemia inhibitory factor (LIF) levels in spontaneous and clomiphene citrate (CC)-induced cycles of patients with unexplained infertility. The patients were followed in two consecutive cycles. Endometrial samples were obtained 7 days after ultrasonographic evidence that ovulation has occurred during the spontaneous cycle, then the patients were induced with CC from day 5 to day 9 during the subsequent cycle with 50 mg/day, and ovulation monitoring and endometrial biopsy were performed in the same manner. The samples were obtained using a Pipelle biopsy device without using local anesthesia, and kept in formaldehyde solution until the day of measurement. Then they were homogenized in phosphate buffered distilled water, and LIF levels were detected in the homogenized fluid by ELISA method. Endometrial LIF levels were 470 +/- 52 and 501 +/- 45 pg/1 gram wet tissue in spontaneous and CC-induced cycles respectively, revealing no significant difference. Ovulation induction with CC did not adversely affect endometrial LIF levels.     

Endometrial biopsy using the Tao Brush method. A study of 50 women in a general gynecologic practice

OBJECTIVE: To test whether the Tao Brush can retrieve sufficient endometrium for diagnosis and also to observe patients' tolerance of its use. STUDY DESIGN: Fifty women underwent Tao Brush sampling: 25 were sampled by Tao Brush alone, and the remainder were sampled by Pipelle immediately following. Patients' reactions to each method were observed. RESULTS: Pipelle currettes larger pieces of endometrium; the Tao Brush obtains smaller pieces. There was no discrepancy between Tao Brush and Pipelle except that Pipelle sampled two of five endometrial polyps, while the Tao Brush sampled none. There was less tissue insufficient for diagnosis with the Tao Brush (2%) than Pipelle (12%). Most patients did not show signs of distress during Tao Brush sampling but grimaced during Pipelle suction curettage. For each of the 16 patients in the second group, the Tao Brush was significantly less painful than Pipelle (P < .01). CONCLUSION: Our data suggest that the Tao Brush is an effective alternative endometrial sampler, causes less pain and produces less tissue insufficient for diagnosis than does the Pipelle. The CPT billing codes (58100) are the same for both the Pipelle and Tao Brush.     

Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling

Objective  To compare factors influencing adequacy of endometrial samples obtained using two outpatient sampling devices – Pipelle and Tao Brush.
Design  Pragmatic unblinded trial with investigation schedule randomised separately within two groups according to endometrial cancer risk.
Setting  Gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland.
Population  All women referred to a gynaecology outpatient clinic during a 28-month period complaining of abnormal vaginal bleeding.
Methods  Women were assigned to two 'risk groups' for endometrial cancer ('high risk' for postmenopausal women and 'moderate risk' for premenopausal women aged over 40 years or with other risk factors). Women in each risk group had both types of biopsy and were randomised to two outpatient visualisations: hysteroscopy and/or transvaginal ultrasound scan.
Main outcome measures  Completion of the investigation, adequacy of sample and acceptability of investigation to women.
Results  In 200 high-risk women, adequate samples were significantly more likely to be obtained by Tao Brush than Pipelle ( P < 0.001). Nulliparity was strongly associated with failed insertion for both devices ( P < 0.001). Inadequate samples were strongly associated with postmenopausal status only for Pipelle ( P < 0.001), and among premenopausal women, for both samplers, with nulliparity ( P < 0.001). A significantly greater proportion of women preferred the Tao Brush to the Pipelle endometrial sampler ( P < 0.001).
Conclusions  In postmenopausal women, Tao Brush sampling offers advantages over use of Pipelle, and the former should be considered as an alternative or additional sampling device in this group of women.     

Evaluation of endometrial biopsy in postmenopausal women before HRT

One of the reasons for not commencing or withdrawal of HRT in women is their fear for breast and endometrial cancers. Does ultrasonographic valuation guarantee sufficiently patient's safety? Most investigators do not recommend further endometrial diagnostics with endometrial thickness less than 4 mm. Endometrial biopsy is advised in cases of irregular uterine bleedings with normal endometrial image or when any endometrial pathology is suspected. In Poland the most frequently performed procedure of endometrial diagnostics is D&C. Our proposition was to offer endometrial biopsies to all patients who were taken HRT for more than 5 years or, despite having strong climacteric ailments, refused to take it because of their cancerophobia. AIM OF STUDY: To evaluate the usefulness of aspiration endometrial biopsy in women after menopause qualified for HRT. MATERIAL AND METHODS: In 84 females, being postmenopausal (amenorrhoeic for at least 12 months) and qualified for HRT, aspiration endometrial biopsies were performed in outpatient clinics. Age of women ranged 46-63 years, mean 57.3. Attained results were compared to ultrasonographic endometrial evaluation. Such factors as patient's age, menopausal age (years from last menstrual period) and previous administration of HRT were taken into our account (maintaining a 3-month wash-out interval). In 74% of women we have got a material being sufficient for histological evaluation. Form clinical point of view the most important for us was to exclude a proliferative or neoplastic process within endometrium. One of endometrial polyps was omitted in USG study, we were surprised also while detecting endometrial carcinoma cells in endometrium below 3.5 mm. In one postoperative slide the cells of endometrial ovarian carcinoma (with infiltrated Fallopian tube) were detected. CONCLUSION: Endometrial biopsy seems to be a useful, effective and cheap method of endometrial diagnostics also in women after menopause.     

Ultrasound and menstrual history in predicting endometrial hyperplasia in polycystic ovary syndrome

OBJECTIVE: To assess the role of endometrial thickness on vaginal ultrasound assessment and menstrual history in predicting endometrial hyperplasia in women with polycystic ovary syndrome (PCOS) who presented with infertility due to anovulation. METHODS: This was a prospective study in a university referral-based fertility and endocrine clinic. Fifty-six women with PCOS presenting with infertility due to anovulation underwent both vaginal ultrasound assessments and endometrial biopsies. The main outcome measures were the predictive value of sonographic endometrial thickness (primary objective) and the menstrual history with other clinical characteristics (secondary objective) for proliferative endometrium and endometrial hyperplasia in logistic regression analysis. Their predictive value was further examined by receiver operating characteristic curve analysis. RESULTS: Thirty-six PCOS patients (64.3%) had proliferative endometrium and 20 (35.7%) had endometrial hyperplasia. Five of the latter (25%) had cytologic atypia. Endometrial thickness less than 7 mm or intermenstrual interval less than 3 months (corresponding to more than four menstrual periods yearly) was associated with proliferative endometrium only. The endometrial thickness correlated positively with endometrial hyperplasia (P =.018) and, together with the average intermenstrual interval, were significant predictors of endometrial hyperplasia (P <.001). CONCLUSION: These findings point to the usefulness of obtaining a detailed menstrual history in women with PCOS by identifying those at increased risk of endometrial hyperplasia and who require an endometrial biopsy. The endometrial thickness corroborates this clinical impression and is particularly useful when the menstrual history is uncertain. Endometrial hyperplasia in this population is effectively excluded when the endometrial thickness is less than 7 mm.