ROMMEL A.

DECENA, MD

Most commonly encountered condition in gynecology. Encompasses any significant deviation

Frequency

Regularity
Heaviness (volume or amount) Duration

In almost all cases, an endometrial involvement or etiology must be ruled out.

Diagnostic curettage
most common method utilized relatively blind procedure usually done under in-patient settings

requiring intravenous sedation or regional anesthesia

Pipelle cannula
utilized in an out-patient setting
obviating the need for admission and possible anesthetic risks and complications

To determine the accuracy of pipelle cannula in diagnosing endometrial pathology among women with abnormal uterine bleeding

To compare the histopathological result of endometrial tissues collected using pipelle cannula with diagnostic curettage. To determine the threshold of endometrial thickness wherein the histopathologic results for both pipelle and diagnostic curettage would be reproducible.

To determine the degree of pain and degree of comfort/discomfort of patients undergoing pipelle curettage.

Diagnostic curettage requires patient to be admitted and be sedated intravenously in order to perform the procedure.
In the absence of significant difference on the

result, pipelle cannula biopsy of endometrial tissue will be recommended as an office procedure in this institution.

The potential benefits for the patients

less medical cost increase man-hours avoiding complications that may arise from anesthesia

during sedation

The potential benefits for the hospital

decrease work load for medical and nursing staff and

thereby focusing more on other patients who needed more attention and care

Patient selection

Prospective Non-Randomized Study Patients screened: Inclusion and Exclusion Criteria Baseline Labs: CBC with platelet count, UA, pregnancy test, UTZ

Consent for procedure obtained Pipelle endometrial sampling questionnaires Endometrial Diagnostic curettage under IV sedation sampling

Statistical analysis of results

Histopathologic examination Summary of results Statistical analysis

frequency and cross tabulation paired t-test weighted mean F-test

RESULTS AND DISCUSSION

Table 1. Comparing the histopathologic results of endometrial tissues collected using pipelle cannula as to diagnostic curettage
Histopathologic Results Placental tissues Normal Polyp Diagnostic Curettage 3 25 53 Pipelle Cannula 5 27 40

Simple Hyperplasia
Simple Hyperplasia with atypia Complex Hyperplasia Complex Hyperplasia with atypia Carcinoma

30
1 1 4 3

33
2 3 6 4

Total

120

120

Table 1.1 Comparing the histopathologic results of endometrial tissues collected using pipelle cannula and diagnostic curettage as to category

Histopathological results

Diagnostic Curettage

Pipelle

Normal Polyp and Hyperplasia Pre-malignant and Malignant

Total

28 85 7
120

32 78 10
120

Prospective study N = 133 postmenopausal women Chief complaint: vaginal bleeding Endorette: a brand of pipelle cannula
have similar diagnostic properties among women

with endometrium of <7 mm

Diagnostic Curettage is superior to Endorette in women with endometrium of > 7 mm

Epstein, E et al. Comparison of Endorette and Dilatation and Curettage for Sampling of the Endometrium in Women with Postmenopausal Bleeding. Acta Obstetricia e tGynecologica Scandinavica. 2001:80:959-964.

Table 2. Comparison of histopathological results of pipelle and Diagnostic Curettage in relation with endometrial thickness
Endometrial thickness Polyp and Hyperplasia Pipelle D&C Pre-malignant and Malignant Pipelle D&C

Normal Pipelle D&C

0.6 to 1

16

13

29

31

1.1 to 2.0

10

11

31

32

1.6 and thicker

18

22

Total

32

28

78

85

10

p value 0.9370

p value 0.7647

P value 0.1428

Table 3.1 Description of the pain during the procedure, from inserting the speculum, grasping the anterior fornix using the tenaculum up to insertion of the pipelle cannula

OB score

Absence of pain

Mild pain

Moderate pain

Severe pain

Very severe pain 0 0

Weighted Mean

Description

G0P0 G1P0 and G1P1

0 2

5 2

8 3

10 1

3.21 2.26

Moderate pain Mild pain

G2P0 and up

15

35

32

2.35

Mild pain

Total

17

42

43

18

2.61

Moderate pain

Table 3.2 Description of pain during collection of endometrial tissues using pipelle cannula

OB score G0P0 G1P0 and G1P1 G2P0 and up Total

Absence of pain 0 2

Mild pain 6 4

Moderate pain 11 2

Severe pain 6 0

Worst pain 0 0

Weighted Mean 3.0 2.0

Description

Moderate pain Mild pain

17

46

19

2.17

Mild pain

19

56

32

13

2.39

Moderate pain

Table 3.3 Comfortability of patients during the procedure, from inserting the speculum, grasping the anterior fornix using the tenaculum up to insertion of the pipelle cannula

OB score G0P0

Yes 15

No 8

Weighted Mean 1.35

Description Affirmative

G1P0/G1P1

1.125

Affirmative

G2P0 and up

80

1.10

Affirmative

Total

102

18

1.19

Affirmative

Table 3.4 Comfortability of patients during the collection of endometrial tissues using the pipelle cannula

OB score G0P0

Yes 16

No 7

Weighted Mean 1.30

Description Affirmative

G1P0/G1P1

1.125

Affirmative

G2P0 and up

81

1.09

Affirmative

Total

104

16

1.17

Affirmative

Table 3.5 Recommendation of patients regarding the pipelle cannula

OB score
G0P0 G1P0/G1P1 G2P0 and up Total

Yes
18 7 82 107

No
5 1 7 13

Weighted Mean
1.21 1.125 1.07 1.14

Description
Affirmative Affirmative Affirmative Affirmative

Author

Study

IN THIS STUDY
Bakkum-Gamez et al. Behnamfar, MD et al. Fakhar S, et al.

100 % of the endometrial tissue samples obtained using the pipelle were adequate for histopathological diagnosis.
Current Issues in the Management of Endometrial Cancer. Mayo Clinic Proceedings: Symposium on Solid Tumors, Mayo Foundation for Medical Education and Research. January 2008;83 (1) 99-100. Diagnostic Value Endometrial Sampling with Pipelle Suction Curettage for Identifying Endometrial Lesion Among Women with Abnormal Uterine Bleeding. Journal of Research in Medicine:2004:3:123-125. Validity of Pipelle Endometrial Sampling in Patients with Abnormal Uterine Bleeding. Annual Saudi Medicine 2008; 28:188-91.

Epstein, E et al.

Comparison of Endorette and Dilatation and Curettage for Sampling of the Endometrium in Women with Postmenopausal Bleeding. Acta Obstetricia e tGynecologica Scandinavica. 2001:80:959-964.
Feasibility and yield of Endometrial Biopsy using Suction curette device for evaluation of abnormal pre and postmenopausal bleeding. Journal of Obstetrics and Gynecology of India. 2008;58(4):322-326. Is Pipelle biopsy really adequate for diagnosing endometrial disease? Med Sci Monit 2004; 10(6): 271-4

Bharti, Bharani, Satish PR. Tanvriverdi HA, et al Yasmin F et al

Efficacy of Pipelle as a tool for endometrial biopsy. Biomedica Vol. 23 (Jul-Dec 2007)

N = 8/120 (6.67%)
Result: Benign endometrial gland and

stroma Comment by the pathologist:

Evaluation is limited by scant endometrial tissues in the submitted specimen

 Insufficient sample generally is not believed

to cause a concern
normal1 as failure to obtain an endometrial specimen from a device correctly positioned within the uterine cavity is considered to be an assurance that no significant intrauterine pathology is present.2
1Epstein,

2001 2004

2Tanniverdi,

Patient Green-MC-048

Pipelle Consistent with well differentiated endometriod adenocarcinoma Consistent with well differentiated endometriod adenocarcinoma

D&C Consistent with well differentiated endometriod adenocarcinoma Simple hyperplasia with focal complex hyperplasia with atypia

TAHBSO Consistent with well diffentiated endometriod adenocarcinoma WHO Grarde 2 Consistent with an endometriod adenocarcinoma WHO Grade 2

White-JG-052

White-GMC-054

Consistent with moderately to poorly differentiated endometriod adenocarcinoma

Moderately differentiated endometriod adenocarcinoma

Moderately differentiated endometriod adenocarcinoma, WHO Grade 2

Orange-AV-074

Consider Malignant Mixed Mullerian Tumor

Malignant Mixed Mullerian Tumor

Malignant Mixed Mullerian Tumor

Endometrial thickness is not a significant factor in using pipelle contrary to the findings of Epstein (2001)

Patient discomfort during pipelle curettage was noted more on nulligravid patients.

Good rapport with the patient and thorough explanation of the procedure give a sense of security and assurance to the patient and may lessen their anxiety.

Endometrial biopsy using pipelle cannula

safe cost-effective office procedure an alternative to a more invasive procedure

The endometrial tissue sample obtained using pipelle is sufficient and adequate for histology. The histopathological result of endometrial tissue sample obtained using pipelle cannula is comparable to that of diagnostic curettage

Endometrial thickness is not a significant factor for using pipelle

A thorough explanation to guarantee that pipelle curettage is a generally safe, and tolerable procedure is recommended to give each patient a sense of security and assurance so as to lessen their anxiety.