THE PROBLEMS WITH ENDOMETRIAL “BIOPSY”

Dr Steven R. Goldstein is a top gynecologist in NYC who has helped thousands of women with gynecological issues and women’s health in over 35 years of private practice. Dr Goldstein comments on the latest revision of the ACOG with regard to endometrial sampling, and points out the problems with endometrial biopsy. 

The new revision of the American College of Obstetricians and Gynecologists calls for endometrial sampling, no matter what the transvaginal ultrasound lining shows, in a huge number of women who bleed during the menopause. I have had a problem with such sampling for many years. Even the American College of Obstetricians and Gynecologists tends to use the words “sampling” and “biopsy” interchangeably.

So, I took the opportunity to look up the definitions of both. The National Cancer Institute defined biopsy as, “taking a piece of tissue for pathologic analysis. This includes needle biopsy, incisional biopsy, and excisional biopsy.” “Sampling” implies taking a portion of something that will be representative of the entire sample. An analogy would be taking some water out of a reservoir to analyze it with the assumption that this is indicative of the entire body of water.

The so called, “biopsy of the uterus” takes a small piece with the assumption that this represents the entire uterine cavity. Studies have shown that when a cancer occupies less than 50% of the surface area of the uterine lining such blind endometrial sampling can be fraught with error. Although the very first study done on 40 women with cancer who had blind sampling in clinic the week before their hysterectomy, they claimed cancer was obtained in 39, yielding an accuracy rate of 97.5%. This had very wide publicity and resulted in a rapid change in the standard of care to utilize such techniques in patients who might have uterine cancers.

In a subsequent study of 65 women with known cancer where they had such blind endometrial sampling done in the operating room just before the initiation of their hysterectomy, 16.5% of the cancers were missed with such blind biopsy samples! That investigator, however, then opened up the uteri and found that in all the cancers that were missed, less than 50% of the surface area was involved. In other words, such tumors are not always global and can be missed. Other investigators have found miss rates of 17%, 33%, and another 33% in patients with known cancers who underwent such biopsy sampling procedures prior to their hysterectomy. The reliability of such endometrial sampling is much lower than the reliability of a well performed, distinct ultrasound evaluation of the endometrial lining.

Yet in this new revision of the ACOG document, although they now advise such individual sampling, there is no commentary or analysis of the potential shortcomings of such sampling. I have objected strenuously to that. But to no avail. Practitioners and patients both need to understand these shortcomings. Hopefully, well informed practitioners will understand this and, in spite of the guidance from the ACOG, not subject all of such patients to invasive endometrial sampling and take it even further when such sampling is unsuccessful.

If you have been told you need an endometrial biopsy as a first means of diagnosis, then don’t! Schedule a consultation with Dr Goldstein, a top NYC Gyn, for a second opinion.