Endometrial Biopsy

Pathologic Findings in 3,600 Biopsies from Selected Patients

D O M I N G O B A I T L O N , M.D., AND J O H N O. H A D L E Y , M.D.*

From the Departments of Pathology and Obstetrics and Gynecology, Parkview Episcopal
Hospital, Pueblo, Colorado 81003

ABSTRACT

Baitlon, Domingo, and Hadley, John O.: Endometrial biopsy. Pathologic

findings in 3,600 biopsies from selected patients. Am. J. Clin. Pathol. 63:
9 - 1 5 , 1975. During a 14-year period (1959-1972), 3,600 endometrial
suction biopsies were performed in the office for specific indications in
selected patients. Three hundred seventy-seven biopsies (10.5%) revealed
abnormal findings. Of these, 233 showed endometritis, 96 associated with
necrotic decidual or placental tissue, or both; one with tuberculosis, and 136
with no specific causative agent. In 84 biopsies endometrial hyperplasia was
present; 34 contained polyps from the cervix or endometrium. Eighteen
malignancies were diagnosed, four of which originated in the cervix and the
remainder in the endometrium. Used judiciously, the procedure is perhaps
the most reliable means of evaluating the uterine cavity short of a formal
dilatation and curettage. (Key words: Endometrium, biopsy.)

IT IS NOW well-recognized that conven- confirmed by examination of tissue re-

tional cytologic screening of vaginal
smears is not sufficienly reliable for the
detection of endometrial cancer 6,11,13 and
is even less useful for the differentiation
of various benign lesions affecting the
endometrium. 13 As a consequence, con-
siderable efforts have been directed to-
wards the development of methods that
could enhance or supplant the vaginal
smear. These methods include aspiration
or aspiration following lavage, 5,9 rotating
a small brush in the endometrial cavity,2
and more recently, jet-washing of the
endometrial cavity for removal of material
for cytologic study. 1,7 As in other cytologic
studies, negative findings are inconclusive,
and suggestive or positive results must be
moved by subsequent biopsy or curettage.
Since the introduction of the suction
curette by Novak 15 and by Randall, 17
many studies regarding the efficacy of the
endometrial biopsy as an easily performed
office procedure have appeared in the
literature. 3,4,16,18_21 Most of these studies
involve small numbers of biopsies, are of
short duration, and deal primarily with
the detection of carcinoma of the en-
dometrium. The present authors report
the pathologic findings in 3,600 endo-
metrial suction biopsies performed in the
office for specific indications during the
past 14 years (1959-1972).
Materials and Methods

* Died, April 4, 1973. Patient Population

Received April 19, 1974; revised July 10, 1974;
accepted for publication July 10, 1974. T h e endometrial biopsies comprising
Address reprint requests to Dr. Baitlon, Depart-
ment of Pathology, Parkview Episcopal Hospital, 400 this study were obtained from patients in
Block West 16th Street, Pueblo, Colorado 81003. the private practice of one of the authors
9

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 10 BAITLON AND HADLEY A.J.C.P.—Vol. 63

Table 1. Indications for Endometrial vaginal discharge, or other pelvic com-

Biopsy
Indication Number
Abnormal uterine bleeding 1,846
Preoperative evaluation 1,274
Infertility studies 265
Miscellaneous 215
3,600
TOTAL
(Dr. Hadley). In all cases, routine history
and physical examination, including pel-
vic examination, were performed prior to
biopsy. Except in instances in which cervi-
cal and vaginal smears had been examined
in the preceding 6 months, these were also
obtained.
Indications for Biopsy
More than half of the biopsies were
done for evaluation of abnormal uterine
bleeding (Table 1). Preoperative evalua-
tion of the uterine cavity in patients with
unexplained pelvic mass, cystocele, or
rectocele or unexplained enlargement of
the uterus in whose cases pregnancy had
been excluded formed the second largest
group. Some patients with infertility had
repeated biopsies over several years. On
occasion, dysmenorrhea, unexplained
plaints served as an indication.
%
Procedure
51.3
35.4
The biopsy procedure is essentially that
7.3 described by Hofmeister. 10 No anesthetic
6.0 was administered. T h e tissue obtained was
100.0
immediately placed in 10% buffered for-
malin, submitted to the laboratory, and
processed with other surgical specimens.
T h e biopsies were sectioned at several
levels and stained with hematoxylin and
eosin. The cervical and vaginal smears
were processed with other cytologic mate-
rial and made available for correlation
with the biopsy.
Results
The majority of the biopsies contained
0.5 to 2.0 gm. of tissue. In some instances,
as much as 8.0 gm. of tissue was obtained.
The specimens were notably free of blood
and extraneous debris, which made in-
terpretation much easier. When tissue
fragments were not grossly visible, the
specimen was considered inadequate and
was submitted for cytologic study.
The histologic findings are summarized
in Table 2. Nearly two thirds of the
abnormal biopsies showed endometritis,

Table 2. Pathologic Findings in 3,600 Endometrial Biopsies

%of
Diagnosis Number Total Biopsies

Endometritis associated with

96 1 97 2.7
decidual and/or placental fragments
Tuberculosis
136 3.8
Endometritis, nonspecific
Endometrial hyperplasia 74 84 2.3
Atypical 10
Hormonal suppression of endometrium Polyp 8 0.2
Of cervix 15 34 0.9
Of endometrium 19
Carcinoma
Of cervix
Of endometrium
Total abnormal biopsies 377 10.5

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 January 1975 ENDOMETRIAL BIOPSY 11

4
51% .

> : |

jtia.'
FIG. 1 (upper). Tuberculous endometritis in a 54-year-old women with a long history of amenorrhea and
infertility. Hematoxylin and eosin. X100.

Fie. 2 (lower). Polypoid cystic hyperplasia in a 24-year-old woman with Stein-Levinthal syndrome.
Hematoxylin and cosin. xlOO.

and 96 of these were associated with
necrotic decidual tissue, with or without
chorionic villi. One hundred thirty-six
biopsies showing endometritis showed no
specific cause. Most of the latter were
obtained from patients also in the child-
bearing age group, with only five cases
occurring in patients more than 50 years
of age. One case of tuberculosis was
diagnosed (Fig. 1).
Eighty-four biopsies showed hyperplasia,
including cases of proliferative hyperplasia,
polypoid cystic hyperplasia of the Stein-
Leventhal type (Fig. 2), and cystic hyper-

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 12 BAITLON AND HADLEY A.J.C.P.—Vol.63

FIG. 3 (upper). State II Squamous-cell carcinoma of the cervix in a 64-year-old women with irregular
"spotting." Hematoxylin and eosin. XlOO.

FIG. 4 (lower). Carcinoma in situ of the endometrium in a 46-year-old woman with metrorrhagia. Several
contiguous glands are partly lined by or contain neoplastic cells. Hematoxylin and eosin. XlOO.

plasia of the post-menopausal variety. T e n Eighteen carcinomas were diagnosed by

cases of hyperplasia showed atypical fea-
tures. Thirty-four polyps were diagnosed,
In some instances, the remainder of the
polyp was subsequently removed at curet-
tage or at hysterectomy.
biopsy. Of these, four were of cervical
origin (Fig. 3), and in each instance, the
cervical smear was also positive (Table 3).
Of the 14 endometrial carcinomas, three
were thought to be in situ (Figs. 4 and 5),

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 January 1975 ENDOMETRIAL BIOPSY 13

FIG. 5 (upper). Cluster of neoplastic cells within an endometrial gland. Stromal invation was not
demonstrated in serial sections. Hematoxylin and eosin. X400.

FIG. 6 (lower). Adenocarcinoma of the endometrium confined to the uterus in a 50-year-old woman with
symptomatic cystocele and rectocele. Hematoxylin and eosin. X100.

and in each instance the vaginal smear
was negative. Curettage confirmed the
diagnosis of carcinoma in situ in one case,
whereas no further carcinoma was found
in the other two. In the 11 cases of
infiltrative carcinoma (Fig. 6), only one
vaginal smear was positive. Six smears
showed "inflammatory atypia," and the
remainder were normal,
Ninety-eight biopsies were inadequate
for histologic examination. Many of these
were from postmenopausal or postpartum

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 14 BAITLON AND HADLEY
Table 3. Comparative Results of Biopsy and
Cytologic Smears in Carcinoma of the
Cervix and Endometrium
Result of
Diagnosis Number Cytologic Smear
Carcinoma of cervix 4 4 positive
Carcinoma-in-situ of
endometrium 3 3 negative
Adenocarcinoma of the
endometrium 11 1 positive
6 "inflammatory
atypia"
4 negative
women, in whom the quantity of en-
dometrium would be expected to be
small. Cytologic examinations of these
specimens were generally not helpful in
clarifying the clinical status of the patient,
and curettage was recommended in the
cases of patients with persistent symptoms.
Discussion
T h e findings in this series of endome-
trial biopsies reflect the pathology of the
endometrium in general 14 and do not
differ considerably from the reports of
others. 10,11 T h e results support the con-
tention that many women with abnormal
uterine bleeding have functional bases for
the bleeding. 8 Although some of these
patients had various extents of prolifera-
tive hyperplasia in the biopsies, most had
no apparent histologic abnormality. The
incidence of malignancy compares favor-
ably with the findings of others in com-
parable series 10 and further substantiates
the low rate of positive vaginal smears in
patients with endometrial carcinoma. T h e
finding of only one case of tuberculosis
also reflects the low incidence of genital
tuberculosis in this country at the present
time. 12
Some findings were unexpected. In the
cases of two of the three patients with
carcinoma in situ, not only were the
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AJ.C.P.—Vol. 63
vaginal smears negative, but subsequent
curettage failed to show residual car-
cinoma. This suggests that perhaps in
some instances carcinoma is discovered at
an early stage and is completely removed
by biopsy. In spite of the large number of
patients taking oral contraceptives
examined during the course of this study,
only a few patients showed hormonal
suppression of the endometrium. A sur-
prisingly large number of women with
abnormal bleeding in the postpartum
period had retained placental and de-
cidual fragments in the biopsies, although
the exact incidence of this occurrence was
not determined in this study. Since the
absence of tissue fragments constituted an
inadequate specimen, a relatively large
number of biopsies was placed in this
category.
The office endometrial biopsy has sev-
eral advantages over other means of
evaluating the endometrium being used
currently. It is valuable not only in the
detection of carcinoma, but also as a
means of differentiating various benign
lesions of the uterine cavity. It is a useful
means of evaluating the uterine tract
prior to hospitalization, with the advan-
tage of availability of a pathologist's re-
port prior to operation. It is invaluable in
the cases of patients requiring periodic
evaluation of the endometrium, such as
women with infertility or those using oral
or mechanical contraceptives.
T h e advantages to the laboratory are
several. Technically, the handling of the
biopsy is simple. As the specimen is placed
directly in formalin, the tissue is well fixed
by the time it arrives in the laboratory.
T h e tissue is processed, sectioned and
stained with other surgical material, and
additional technical staff for special prep-
aration and screening, such as are re-
quired with cytologic methods, is not
necessary.
Pathologically, the quantity of tissue
obtained generally reflects the functional
 January 1975 ENDOMETRIAL BIOPSY
or pathologic state of the endometrium at
the time of biopsy. Ordinarily, only small
amounts are obtained from the post-
menopausal women unless hyperplasia or
carcinoma exists. Nearly all pathologists
are familiar with the histologic interpreta-
tion of endometrial specimens. In con-
trast, interpretation of cytologic material
from the endometrium requires consider-
able experience and expertise in order to
be meaningful. As the diagnosis made on
the basis of a biopsy is histologic, addi-
tional confirmatory procedures are not
ordinarily required.
Perhaps a major barrier to the routine
use of the endometrial biopsy at present is
the small number of physicians familiar
with the procedure. It is relatively time-
consuming and is not a very versatile
screening device. The inadvertent inter-
ruption of a pregnancy that would other-
wise proceed to term is a potential hazard,
but this factor is also a consideration in
other procedures used to sample the
endometrium. As no anesthetic was used,
complaints of transient discomfort or pain
during the procedure were frequent.
However, no serious complication oc-
curred, and no pregnancy was interrupted
during the couse of this study.
When used judiciously in selected pa-
tients for specific indications, the benefits
from the procedure outweigh the few
potential disadvantages. As ambulatory
medicine assumes a larger role in the care
of patients, the endometrial biopsy should
become a more valuable diagnostic proce-
dure.
References
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tive study of the endometrial jet-washing
technic and endometrial biopsy. Am J Clin
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15
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