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OG34.4 | Minor Operative Gynaecology — SDL Guide (Part 2)

Endometrial Aspiration, ECC, and Cervical Biopsy — Technique

These procedures share the goal of obtaining tissue from the uterine cavity or cervix for histological diagnosis, but differ in setting (outpatient vs theatre), anaesthesia requirement, specimen adequacy, and diagnostic sensitivity. Understanding the technical nuances of each improves diagnostic yield and patient experience.

Endometrial aspiration (Pipelle technique): The Pipelle de Cornier is a flexible 3.1 mm outer diameter polypropylene sheath with a piston that creates suction when the inner rod is withdrawn. The technique is as follows: (1) visualise the cervix with a speculum; (2) no cervical dilatation is usually needed (the Pipelle is narrow enough to pass through the internal os in most women); (3) introduce the Pipelle gently through the external os and advance to the uterine fundus; (4) withdraw the inner piston to create negative pressure (suction); (5) rotate the Pipelle and move it in and out with strokes covering all four walls; (6) remove and expel contents into fixative. The entire procedure takes 1–2 minutes. Sensitivity for endometrial carcinoma: approximately 91% in studies (comparable to D&C for carcinoma detection; lower for polyps and focal hyperplasia). An inadequate sample (insufficient material for histology) in a symptomatic postmenopausal woman mandates hysteroscopy + directed biopsy.

Endocervical curettage (ECC): A small (Kevorkian or similar) curette is introduced into the endocervical canal without dilating the cervix (to avoid contamination from the uterine cavity). Systematic scraping of the canal walls yields an endocervical specimen. In fractional curettage, ECC is performed first and specimen labelled separately, THEN the endometrial curettage proceeds — preserving the integrity of endocervical sampling before dilatation.

Colposcopy-directed cervical punch biopsy: (1) Apply 3–5% acetic acid to the cervix; identify the transformation zone (TZ) and acetowhite areas; (2) Apply Lugol's iodine if needed (iodine-negative = Schiller positive = abnormal glycogen-poor epithelium); (3) Use a Kevorkian or similar punch biopsy forceps to take 3–5 mm tissue cylinder from the most abnormal area of the TZ; (4) Haemostasis with Monsel's solution (ferric subsulphate), silver nitrate, or pressure; (5) Label specimens separately if multiple sites biopsied. No anaesthesia is typically needed; the patient experiences brief sharp discomfort. The procedure is performed at colposcopy after an abnormal cervical smear.

Sampling Method	Setting	Anaesthesia	Sensitivity for Carcinoma	Key Limitation
Pipelle aspiration	Outpatient	Usually none	~91%	Inadequate rate ~10–15%; misses focal lesions
Vabra aspirator	Outpatient	Paracervical block	~95%	More uncomfortable than Pipelle
D&C (blind)	Theatre	GA/spinal	~80–85%	Misses focal lesions (polyps, focal Ca)
Hysteroscopy + biopsy	Theatre/OPD	Variable	>95%	Equipment-dependent; most accurate

Interpretation of Findings

The clinical value of D&C, endometrial aspiration, ECC, and cervical biopsy lies in the histopathological findings they yield. The clinician ordering these procedures must understand the range of expected findings and their clinical implications, both to counsel patients pre-operatively and to action the results appropriately.

Endometrial histology (from D&C or EA): Normal proliferative or secretory endometrium indicates no structural pathology (though dysfunctional uterine bleeding can still occur). Endometrial polyp (irregular glandular overgrowth on a fibrovascular stalk): benign in most, but ~0.5% harbour carcinoma; usually requires hysteroscopic polypectomy. Simple hyperplasia without atypia: low malignant potential (~1% cancer risk over 10 years); managed with progestogens or LNG-IUS. Complex hyperplasia without atypia: ~3% cancer risk; progestogen treatment and surveillance. Simple/Complex hyperplasia WITH atypia (endometrial intraepithelial neoplasia): ~25–30% cancer risk; hysterectomy recommended. Endometrial carcinoma: requires full staging investigations and surgical management. Inadequate sample: cannot exclude pathology; proceed to hysteroscopy if clinically indicated. Atrophic endometrium: common in postmenopausal women; reassuring when the clinical presentation is low-risk, but does not exclude focal cancer.

Endocervical histology (from ECC): Normal endocervical epithelium. Endocervical glandular dysplasia (adenocarcinoma in situ, AIS): requires excision (cone biopsy/LLETZ) as it may extend into the canal beyond colposcopy's view. Cervical adenocarcinoma: less common than squamous but increasing in incidence; HPV-18 associated.

Cervical biopsy histology: Normal ectocervix or metaplastic TZ. CIN 1 (low-grade squamous intraepithelial lesion, LSIL): usually regresses spontaneously; surveillance colposcopy. CIN 2/3 (high-grade squamous intraepithelial lesion, HSIL): requires treatment (LLETZ excision). Squamous cell carcinoma: invasive cancer requiring staging and oncological management (OG34.1).

Inadequate cervical biopsy occurs when the biopsy misses the lesion (targeting error), samples too superficially (no stroma), or is too small. It requires repeat colposcopy and biopsy.

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Complications and Their Management

Complications of minor gynaecological procedures are uncommon but clinically important — the consenting doctor must discuss each with the patient before the procedure. Complications are classified as immediate (intraoperative or within hours), early (within 2 weeks), and late (weeks to months after the procedure).

Immediate complications:

Uterine perforation is the most serious immediate complication. Incidence: approximately 0.3–1.3% for D&C (higher in postmenopausal uterus, post-partum uterus, and when performed by inexperienced operators). The perforation is typically fundal (thin myometrium at the fundus) and often results from the uterine sound or the first dilator. Recognition: sudden loss of resistance with instrument advancing further than the measured cavity depth; instrument passes beyond the expected fundal limit. Management: (a) if the perforation is recognised with a small sound only, and there is no bleeding or suspicion of bowel injury — observe for 24–48 hours conservatively (vital signs, haematocrit, pain); (b) if there is bleeding, visceral injury suspected (bowel smell, omentum prolapsing through the perforation), or if the procedure was being done for evacuation of retained products — proceed to diagnostic laparoscopy to inspect the perforation and exclude bowel injury; (c) laparotomy is rarely needed but necessary for bowel injury or significant intraperitoneal haemorrhage.

Cervical laceration: from tenaculum slipping or forceful dilatation, especially in a stenotic cervix. Usually managed with direct pressure or a suture.

Haemorrhage: intraoperative bleeding from the endometrium or cervix; managed with uterotonics (oxytocin IV), gauze packing, or Foley balloon tamponade.

Anaesthetic complications: standard risks of GA/spinal.

Early complications:

Endometritis/pelvic infection: fever, uterine tenderness, purulent discharge within days to 2 weeks. Risk is higher in women with pre-existing PID, STI, or immunosuppression. Treated with broad-spectrum antibiotics (doxycycline + metronidazole, or cephalosporin + metronidazole). Antibiotic prophylaxis pre-D&C is recommended in high-risk patients.

Late complications:

Asherman syndrome (intrauterine adhesions/synechiae): the most clinically significant long-term complication. Results from overzealous curettage that strips the stratum basalis (regenerative layer) of the endometrium, especially when done in the post-partum or post-abortal period when the endometrium is soft and adherent. Clinical features: secondary amenorrhoea or hypomenorrhoea, cyclical pelvic pain (haematometra), and infertility. Risk is highest after postpartum D&C for retained placenta or missed/incomplete abortion (incidence up to 30% in some series). Diagnosed by hysteroscopy. Treatment: hysteroscopic adhesiolysis followed by oestrogen therapy and an intrauterine splint to prevent re-adhesion.

Cervical stenosis: a late complication of repeated D&Cs or traumatic dilatation, causing obstruction at the internal os; may result in haematometra (blood accumulating in the uterine cavity).

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