Pipelle Endometrial Sampling (Procedure)

To make a diagnosis of, or exclude malignancy and premalignancy, it is necessary to obtain an endometrial biopsy for histological examination. The Cornier pipelle is a disposable polypropylene sheath with an inner plunger and is used for blind endometrial biopsy. It does not require a general anaesthetic.

Endometrial biopsy should be considered in the following women:

• All women aged >40 years with abnormal bleeding.
• Younger women with risk factors for endometrial cancer:
  • Nulliparity (pregnancy protects against endometrial carcinoma by interrupting the continued stimulation of the endometrium by oestrogen)
  • Family history of endometrial or colonic cancer
  • A history of abnormal smears
  • Obesity
  • Polycystic ovary syndrome
  • Tamoxifen therapy
  • Unopposed oestrogen therapy
• Younger women in whom abnormal bleeding does not resolve with medical treatment.

It also has a role in screening for hereditary non-polyposis colorectal carcinoma; it is prudent to screen for gynaecological tumours in mutation positive families, irrespective of family history, as 40% of female gene carriers develop endometrial carcinomas.¹

The patient should have the procedure fully explained to her. A chaperone should be offered. A clean modesty blanket should be available. The use of oral non-steroidal anti-inflammatories e.g. mefenamic acid 500 mg, prior to the procedure can reduce the post-procedure symptoms of pain and cramp.

• Bimanual examination to assess the size and position of the uterus.
• The cervix is visualised using a vaginal speculum and cleaned.
• Recent research has looked at transcervical instillation of 5 mls 2% lignocaine. This was shown significantly to reduce pain during endometrial sampling.²
• A tenaculum applied to the anterior lip of the cervix is used to provide gentle traction whilst a sound is inserted though the cervical os. This reduces the risk of uterine perforation. The tenaculum should be used to straighten the uterocervical canal, thereby preventing the pipelle from passing through the thin walled posterior vaginal wall.
• Dilators may be required if there is difficulty in passing the sound.
• When the position and size of the uterine cavity have been assessed, the pipelle is inserted through the cervical os and advanced until gentle resistance is felt.
• The inner piston of the device is then withdrawn to create suction and the endometrial sample is obtained by moving the pipelle up and down within the uterine cavity by approximately 2-3 cm but not beyond the cervical os. As the cannula is rotated during removal, a strip of endometrium is peeled off and sucked into the syringe.
• This procedure should be repeated at least four times and the device rotated 360 degrees to ensure adequate coverage of the area.
• The pipelle is then withdrawn from the cervical os and the endometrial sample expelled into a solution of formalin for transport to the laboratory.

Pipelle endometrial sampling can also be combined with hysteroscopy.

These include:

• Prolonged bleeding
• Infection
• Uterine perforation
• Post-procedure pain and cramps

Bacteraemia can occur after endometrial sampling and antibiotic prophylaxis must be given to patients at risk of endocarditis.³

These include:

• Pregnancy
• Acute vaginal or cervical infection
• Pelvic inflammatory disease
• Clotting disorders

• Pipelle endometrial biopsy is a cost-effective and safe procedure that is well tolerated by patients.
• There is less pain and a lower risk of perforation with the pipelle than with the Novak curette.⁴
• In addition the pipelle is more portable than the Novak curette and the Vabra aspirator, both of which require external suction.
• The detection rates for endometrial carcinoma using the pipelle device were found by one metanalysis to be 99.6% in postmenopausal and 91% in premenopausal women.⁵
• In postmenopausal women the combined use of pipelle sampling and ultrasound has a high detection rate for endometrial carcinoma.^6,7
• The pipelle is, however, poor at detecting endometrial pathologies such as polyps and submucosal myomas.⁶
• Pipelle aspirates provide accurate endometrial sampling in premenopausal patients with abnormal uterine bleeding.⁸
• However, sampling error is greater with the pipelle and the device samples only 4% of the endometrium compared with 42% with the Vabra aspirator.⁹