2.preventive gynecology

Preventive Medicine in

Women’s Health

OFFICE GYNECOLOGY

Preventive Medicine in

Women’s Health

OFFICE GYNECOLOGY

H. B. Albaño, MD. FPOGSH. B. Albaño, MD. FPOGS

Overview of frequently used diagnostic procedures in gynecologyOverview of frequently used diagnostic procedures in gynecology

Tests for Vulvovaginitis Gram Stain Culture & Sensitivity Test Vaginal pH Whiff Test KOH Smear

Tests for Vulvovaginitis Gram Stain Culture & Sensitivity Test Vaginal pH Whiff Test KOH Smear

Overview of frequently used diagnostic procedures in gynecologyOverview of frequently used diagnostic procedures in gynecology

Screening Tests for Cancer of the Cervix Visual inspection using Acetic Acid

(VIA) Papanicoulau Smear (Pap Smear)

Screening Tests for Cancer of the Cervix Visual inspection using Acetic Acid

(VIA) Papanicoulau Smear (Pap Smear)

Overview of frequently used diagnostic procedures in gynecology

Overview of frequently used diagnostic procedures in gynecology Endometrial biopsy BBT Maturation Index Fern test Spinnbarkheit Test Serum progesterone or urinary

progesterone metabolites levelsdetermination

Endometrial biopsy BBT Maturation Index Fern test Spinnbarkheit Test Serum progesterone or urinary

progesterone metabolites levelsdetermination



Colposcopy Ultrasound Magnetic Resonance Imaging (MRI) Computed Tonography Scan Hysteroscopy Hysterosalpingography

Colposcopy Ultrasound Magnetic Resonance Imaging (MRI) Computed Tonography Scan Hysteroscopy Hysterosalpingography

Gram stain for Vaginal InfectionsGram stain for Vaginal Infections

A sample of the vaginal discharge is placed on a microscope slide.

A special dye (Gram Stain) is put on the slide.

This causes certain types of bacteria: Gram-positive bacteria to turn a shade of

purple Gram-negative bacteria turn pink.

Ex. Gardnerella - Gm (-) Bacterial vaginosis

A sample of the vaginal discharge is placed on a microscope slide.

A special dye (Gram Stain) is put on the slide.

This causes certain types of bacteria: Gram-positive bacteria to turn a shade of

purple Gram-negative bacteria turn pink.

Ex. Gardnerella - Gm (-) Bacterial vaginosis

Vaginal pH TestVaginal pH Test

pH test paper & a color chart for determining your vaginal pH:

To perform the test, hold the pH test paper

against the wall of your vagina for a few seconds.

compare the color of your pH test paper to the color chart.

choose the color your test result most closely resembles to the pH paper.

pH test paper & a color chart for determining your vaginal pH:

To perform the test, hold the pH test paper

against the wall of your vagina for a few seconds.

compare the color of your pH test paper to the color chart.

choose the color your test result most closely resembles to the pH paper.

Vaginal pH Vaginal pH Normal vaginal pH - 3.8 - 4.5 (slightly acidic) Maintained by lactobacillus, which produce

hydrogen peroxide; diphtheroids & Staphylococcus epidermidis.

May increase with age & phase of menstrual cycle, sexual activity, contraception choice, pregnancy, presence of necrotic tissue or foreign bodies, use of hygienic products or antibiotics, infections

Normal vaginal pH - 3.8 - 4.5 (slightly acidic) Maintained by lactobacillus, which produce

hydrogen peroxide; diphtheroids & Staphylococcus epidermidis.

May increase with age & phase of menstrual cycle, sexual activity, contraception choice, pregnancy, presence of necrotic tissue or foreign bodies, use of hygienic products or antibiotics, infections

Vaginal pH TestVaginal pH Test

Conditions pH

Normal vaginal pH 3.8 - 4.5

Bacterial vaginosis > 4.5

Vulvovaginal candidiasis (VVC) ≤ 4.5

Trichomonas vaginalis > 4.5

Whiff TestWhiff Test

Drops of a 10% potassium hydroxide (KOH) solution are added to a sample of vaginal discharge.

(+) Whiff Test A FISHY AMINE odor

Suggestive of Bacterial vaginosis (BV)


(+) Whiff Test A FISHY AMINE odor

Suggestive of Bacterial vaginosis (BV)

Four clinical criteria for the diagnosis of bacterial vaginosis (must meet 3 of 4) Four clinical criteria for the diagnosis of bacterial vaginosis (must meet 3 of 4)

(1)a homogeneous vaginal discharge is present;

(2)the vaginal discharge has a pH equal to or greater than 4.5;

(3)the vaginal discharge has an amine-like odor when mixed with KOH; whiff tests;

(4)a wet smear of the vaginal discharge demonstrates clue cells greater in number than 20% of the number of the vaginal epithelial cells.

(1)a homogeneous vaginal discharge is present;

(2)the vaginal discharge has a pH equal to or greater than 4.5;

(3)the vaginal discharge has an amine-like odor when mixed with KOH; whiff tests;

(4)a wet smear of the vaginal discharge demonstrates clue cells greater in number than 20% of the number of the vaginal epithelial cells.

Wet mount with NSS Wet mount with NSS

• Drops of a normal saline solution (NSS) are added to a sample of vaginal discharge in a glass slide.

• Examine directly under microscope with the 400x objective.

• Drops of a normal saline solution (NSS) are added to a sample of vaginal discharge in a glass slide.

• Examine directly under microscope with the 400x objective.

Wet mount with NSSWet mount with NSS

The presence of squamous epithelial cells laden with macrophages

(+) clue cells -

- Bacterial vaginosis (BV)

The presence of squamous epithelial cells laden with macrophages

(+) clue cells -

- Bacterial vaginosis (BV)

Hanging Drop Technique Hanging Drop Technique • Drops of a normal saline solution

(NSS) are added to a sample of vaginal discharge in a SPECIAL glass slide with a concavity at the center.

• Put a cover slip, invert the slide & examine directly under the microscope under the 400x objective.

• Drops of a normal saline solution (NSS) are added to a sample of vaginal discharge in a SPECIAL glass slide with a concavity at the center.

• Put a cover slip, invert the slide & examine directly under the microscope under the 400x objective.

Hanging Drop TechniqueHanging Drop Technique Presence of

motile protozoans with undulating membranes -

- Trichomonas

vaginalis

Presence of motile protozoans with undulating membranes -

- Trichomonas

vaginalis

KOH SmearKOH Smear

A simple and reliable technique for diagnosis of vulvovaginal candidiasis (VVC).


Examine in the microscopic under the 100X objective.

A simple and reliable technique for diagnosis of vulvovaginal candidiasis (VVC).


Examine in the microscopic under the 100X objective.

KOH SmearKOH Smear

The presence of hyphae -

Candida albicans C. albicans a commensal

agent in 15-20% of women

Vulvovaginal candidiasis (VVC)

The presence of hyphae -

Candida albicans C. albicans a commensal

agent in 15-20% of women

Vulvovaginal candidiasis (VVC)

Screening Tests for Cancer of the CervixScreening Tests for Cancer of the CervixFor Early Detection of Cancer of the Cervix: Visual Inspection with Acetic Acid Papaniculao Smear

Pap Smear or Pap Test

Cancer in Women: 1. Breast 2. Cervix 3. Colon

For Early Detection of Cancer of the Cervix: Visual Inspection with Acetic Acid Papaniculao Smear

Pap Smear or Pap Test

Cancer in Women: 1. Breast 2. Cervix 3. Colon

Types of visual inspection tests:Types of visual inspection tests:

Visual inspection with acetic acid (VIA) can be done with the naked eye - cervicoscopy or direct visual

inspection [DVI]), or with low magnification - gynoscopy, aided VI, or

VIAM.

Visual inspection with Lugol’s iodine (VILI), also known as Schiller’s test

uses Lugol’s iodine instead of acetic acid.

Visual inspection with acetic acid (VIA) can be done with the naked eye - cervicoscopy or direct visual

inspection [DVI]), or with low magnification - gynoscopy, aided VI, or

VIAM.

Visual inspection with Lugol’s iodine (VILI), also known as Schiller’s test

uses Lugol’s iodine instead of acetic acid.

What does VIA involve?What does VIA involve?

Performing a vaginal speculum exam during which a dilute (3-5%) acetic acid (vinegar) is applied to the cervix. Abnormal tissue temporarily appears white

when exposed to vinegar. Viewing the cervix with the naked eye

to identify color changes on the cervix. Determining whether the test result is

positive or negative for possible precancerous lesions or cancer.

Performing a vaginal speculum exam during which a dilute (3-5%) acetic acid (vinegar) is applied to the cervix. Abnormal tissue temporarily appears white

when exposed to vinegar. Viewing the cervix with the naked eye

to identify color changes on the cervix. Determining whether the test result is

positive or negative for possible precancerous lesions or cancer.

What infrastructure does VIA require?What infrastructure does VIA require?

Private exam area Examination table Trained health professionals Adequate light source Sterile vaginal speculum New examination gloves, or HLD surgical gloves Large cotton swabs Dilute (3-5%) acetic acid (vinegar) and a small

bowl Containers with 0.5% chlorine solution A plastic bucket with a plastic bag Quality assurance system to maximize accuracy

Private exam area Examination table Trained health professionals Adequate light source Sterile vaginal speculum New examination gloves, or HLD surgical gloves Large cotton swabs Dilute (3-5%) acetic acid (vinegar) and a small

bowl Containers with 0.5% chlorine solution A plastic bucket with a plastic bag Quality assurance system to maximize accuracy

Categories for VIA test results:Categories for VIA test results:

VIA Category Clinical Findings

Test-negative No acetowhite lesions or faint acetowhite lesions; polyp, cervicitis, inflammation, Nabothian cysts.

Test-positive Sharp, distinct, well-defined, dense (opaque/dull or oyster white) acetowhite areas—with or without raised margins touching the squamocolumnar junction (SCJ); leukoplakia and warts.

Suspicious for cancer

Clinically visible ulcerative, cauliflower-like growth or ulcer; oozing and/or bleeding on touch.

Categories for VIA tests results:Categories for VIA tests results: Acetowhite area far from squamocolumnar junction (SCJ) and

not touching it is insignificant.

Acetowhite area adjacent to SCJ is significant.

Acetowhite area far from squamocolumnar junction (SCJ) and not touching it is insignificant.

Acetowhite area adjacent to SCJ is significant.

Negative PositivePhoto source: JHPIEGO

Categories for VIA tests results:Categories for VIA tests results:

Suspicious for cancerSuspicious for cancer

Photo source: PAHO, Jose Jeronimo

Management options: What to do if the VIA test is positive?Management options: What to do if the VIA test is positive?

Offer to treat immediately.

Refer for confirmatory diagnosis or adjunctive test.

Offer to treat immediately.

Refer for confirmatory diagnosis or adjunctive test.

Schiller’s test:Schiller’s test:

Visual inspection with Lugol’s iodine (VILI), uses Lugol’s iodine instead of acetic acid.

A vaginal speculum exam during which a health care provider applies Lugol’s iodine solution to the cervix.

Visual inspection with Lugol’s iodine (VILI), uses Lugol’s iodine instead of acetic acid.

A vaginal speculum exam during which a health care provider applies Lugol’s iodine solution to the cervix.

How VILI works:How VILI works:

Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen.

Iodine is glycophilic and is taken up by the squamous epithelium, staining it mahogany brown or black.

Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen.

Iodine is glycophilic and is taken up by the squamous epithelium, staining it mahogany brown or black.

How VILI works:How VILI works:

Columnar epithelium does not change color, as it has no glycogen.

Immature metaplasia and inflammatory lesions are at most only partially glycogenated and, when stained appear as scattered, ill-defined uptake areas.

Precancerous lesions and invasive cancer do not take up iodine (as they lack glycogen) appear as well-defined, thick, mustard or saffron

yellow areas.

Columnar epithelium does not change color, as it has no glycogen.

Immature metaplasia and inflammatory lesions are at most only partially glycogenated and, when stained appear as scattered, ill-defined uptake areas.

Precancerous lesions and invasive cancer do not take up iodine (as they lack glycogen) appear as well-defined, thick, mustard or saffron

yellow areas.

Categories for Schiller’s test results:Categories for Schiller’s test results:

Category Clinical Findings

Test-negative Squamous epithelium turns brown and columnar epithelium does not change color; or irregular, partial or non-iodine uptake areas appear.

Test-positive Well-defined, bright yellow iodine non-uptake areas touching the squamo-columnar junction (SCJ) or close to the os if SCJ is not seen.

Suspicious for cancer

Clinically visible ulcerative, cauliflower- like growth or ulcer; oozing and/or bleeding on touch.

VILI: test-negativeVILI: test-negative

The squamous epithelium turns brown and columnar epithelium does not change color.

There are scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation.

The squamous epithelium turns brown and columnar epithelium does not change color.

There are scattered and irregular, partial or non-iodine uptake areas associated with immature squamous metaplasia or inflammation.

Photo source: IARC

VILI: test-positiveVILI: test-positive

Well-defined, bright yellow iodine non-uptake areas touching the squamocolumnar junction (SCJ).

Well-defined, bright yellow iodine non-uptake areas close to the os if SCJ is not seen, or covering the entire cervix.

Well-defined, bright yellow iodine non-uptake areas touching the squamocolumnar junction (SCJ).

Well-defined, bright yellow iodine non-uptake areas close to the os if SCJ is not seen, or covering the entire cervix.

Photo source: IARC

VILI: Suspicious for cancerVILI: Suspicious for cancer



Photo source: IARC

Management options if the VILI result is positive:Management options if the VILI result is positive:

Offer to treat immediately. without colposcopy or biopsy,

known as the “test-and-treat” or “single-visit” approach.

Refer for colposcopy and biopsy and then offer treatment if a precancerous lesion is confirmed.

Offer to treat immediately. without colposcopy or biopsy,

known as the “test-and-treat” or “single-visit” approach.

Refer for colposcopy and biopsy and then offer treatment if a precancerous lesion is confirmed.

Management options if the VILI result is suspicious for cancer:Management options if the VILI result is suspicious for cancer:

Refer for colposcopy and biopsy and further management: Surgery Radiotherapy Chemotherapy Palliative care

Refer for colposcopy and biopsy and further management: Surgery Radiotherapy Chemotherapy Palliative care

Papanicolaou SmearPapanicolaou Smear

Screening or Early Detection for Cancer of the Cervix

Cervical cytology testing

Done by examining a cellular sample scraped from the uterine cervix and properly prepared and stained.

Screening or Early Detection for Cancer of the Cervix

Cervical cytology testing

Done by examining a cellular sample scraped from the uterine cervix and properly prepared and stained.

Pap SmearPap Smear

Initial screening should begin at age 21 or 3 years after the individual becomes sexually

active. High-risk women, those with a history of early

sexual activity and multiple partners, ANNUALLY. Those with later exposure to coitus who have only

one sexual partner and who have had three successive negative annual smears may be considered low risk and should be screened every 2 to 3 years at the discretion of the physician.

Initial screening should begin at age 21 or 3 years after the individual becomes sexually

active. High-risk women, those with a history of early

sexual activity and multiple partners, ANNUALLY. Those with later exposure to coitus who have only

one sexual partner and who have had three successive negative annual smears may be considered low risk and should be screened every 2 to 3 years at the discretion of the physician.

Technique of Pap SmearTechnique of Pap Smear

The cervix must be visualized after placement of a speculum into the vagina.

The portio of the cervix is then scraped using either a "broom" or the combination of a plastic spatula and an endocervical brush.

The cervix must be visualized after placement of a speculum into the vagina.

The portio of the cervix is then scraped using either a "broom" or the combination of a plastic spatula and an endocervical brush.

Pap Smear: ObjectivePap Smear: Objective

To sample exfoliated cells from the endocervical canal and to scrape the transitional zone.

It is also useful to sample the vaginal pool.

To sample exfoliated cells from the endocervical canal and to scrape the transitional zone.

It is also useful to sample the vaginal pool.

Technique (1) of Pap SmearTechnique (1) of Pap Smear The endocervical

canal is sampled using a cotton-tipped

applicator or a cytobrush,

which is placed into the canal and rotated to dislodge the cells.

The endocervical canal is sampled using a cotton-tipped

applicator or a cytobrush,

which is placed into the canal and rotated to dislodge the cells. the cytobrush appears to give

more accurate results & higher yields of positive findings.

Technique (1) of Pap SmearTechnique (1) of Pap Smear The material obtained is

then smeared thinly on a microscope slide by rotation of the swab or brush on the glass surface.

This is labeled endocervix and fixed immediately by use of a spray

fixative or by immersion of the

slide into a fixative solution.

Do not allow to air-dry.

The material obtained is then smeared thinly on a microscope slide by rotation of the swab or brush on the glass surface.

This is labeled endocervix and fixed immediately by use of a spray

fixative or by immersion of the

slide into a fixative solution.

Do not allow to air-dry.

Technique (2) of Pap SmearTechnique (2) of Pap Smear Using the Ayres

spatula the entire transformation zone is scraped and the sample smeared thinly on a second slide, which is immediately fixed.

A sample of the vaginal pool, this may be taken with the reverse side of the Ayres spatula.

Using the Ayres spatula the entire transformation zone is scraped and the sample smeared thinly on a second slide, which is immediately fixed.

A sample of the vaginal pool, this may be taken with the reverse side of the Ayres spatula.

Recent data suggest an extended-tip spatula is better for collecting endocervical cells.Best results come from using both the cytobrush & an extended-tip spatula.

Technique (2) of Pap SmearTechnique (2) of Pap Smear Using the Ayres

spatula the entire transformation zone is scraped and the sample smeared thinly on a second slide, which is immediately fixed.

A sample from the vaginal pool may be collected also.

Using the Ayres spatula the entire transformation zone is scraped and the sample smeared thinly on a second slide, which is immediately fixed.

A sample from the vaginal pool may be collected also.

Fixatives for Pap SmearFixatives for Pap Smear

It is important that fixative be applied immediately before drying and distortion of the cells takes place. Hair Spray fixative 95% ethyl alcohol solution Newer liquid-based, thin-layer Pap smear

preparations are available. No slides are needed. The cytobrush and spatula are used to

obtain cervical cells & are placed in a liquid jar of fixative and gently rotated to dislodge cells in the liquid.

It is important that fixative be applied immediately before drying and distortion of the cells takes place. Hair Spray fixative 95% ethyl alcohol solution Newer liquid-based, thin-layer Pap smear

preparations are available. No slides are needed. The cytobrush and spatula are used to

obtain cervical cells & are placed in a liquid jar of fixative and gently rotated to dislodge cells in the liquid.

Fixatives for Pap SmearFixatives for Pap Smear

It is important that fixative be applied immediately before drying and distortion of the cells takes place. Hair Spray fixative 95% ethyl alcohol solution Newer liquid-based, thin-layer Pap smear preparations

are available. No slides are needed. The cytobrush and spatula are used to obtain

cervical cells as described earlier, and they both are placed in a liquid jar of fixative and gently rotated to dislodge cells in the liquid.

Evidence-based data show both Pap slide prepared in a conventional manner and liquid-based methods for cervical cytology screening are acceptable.

It is important that fixative be applied immediately before drying and distortion of the cells takes place. Hair Spray fixative 95% ethyl alcohol solution Newer liquid-based, thin-layer Pap smear preparations

are available. No slides are needed. The cytobrush and spatula are used to obtain

cervical cells as described earlier, and they both are placed in a liquid jar of fixative and gently rotated to dislodge cells in the liquid.

Evidence-based data show both Pap slide prepared in a conventional manner and liquid-based methods for cervical cytology screening are acceptable.

Pap Smear Result using the following descriptive system (2001 Bethesda system)


Negative for Intraepithelial Lesion or Malignancy

Epithelial Cell Abnormality Squamous cell

Atypical squamous cells (ASC) ･ Low-grade squamous intraepithelial

lesions (LSIL) ･ High-grade squamous intraepithelial

lesions (HGSIL) ･ Squamous cell carcinoma ･


Epithelial Cell Abnormality Squamous cell

Atypical squamous cells (ASC) ･ Low-grade squamous intraepithelial

lesions (LSIL) ･ High-grade squamous intraepithelial

lesions (HGSIL) ･ Squamous cell carcinoma ･




Epithelial Cell Abnormality Glandular cell

Atypical glandular cells (AGC) Typical glandular cells - favor neoplastic Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma


Epithelial Cell Abnormality Glandular cell

Atypical glandular cells (AGC) Typical glandular cells - favor neoplastic Endocervical adenocarcinoma in situ (AIS) Adenocarcinoma



Negative for Intraepithelial Lesion or Malignancy Epithelial Cell Abnormality Interpretation/Result

Other nonneoplastic findings: Reactive

Inflammation Radiation intrauterine contraceptive device

Glandular cells status posthysterectomy Atrophy

Negative for Intraepithelial Lesion or Malignancy Epithelial Cell Abnormality Interpretation/Result

Other nonneoplastic findings: Reactive

Inflammation Radiation intrauterine contraceptive device

Glandular cells status posthysterectomy Atrophy



Negative for Intraepithelial Lesion or Malignancy ･ Epithelial Cell Abnormality Interpretation/Result ･

Organisms ･ Cellular changes consistent with herpes

simplex Trichomonas vaginalis infection Bacteria consistent with Actinomyces

infection Fungal organisms Shift in flora suggestive of bacterial

vaginosis

Negative for Intraepithelial Lesion or Malignancy ･ Epithelial Cell Abnormality Interpretation/Result ･

Organisms ･ Cellular changes consistent with herpes

simplex Trichomonas vaginalis infection Bacteria consistent with Actinomyces

infection Fungal organisms Shift in flora suggestive of bacterial

vaginosis

C/S Test for GC & ChlamydiaC/S Test for GC & Chlamydia

Indications, particularly with new patients and women younger than 25 y.o. it is appropriate to culture & sensitivity test

for gonorrhea and Chlamydia

using swabs that sample secretions from the endocervical canal.

This step may be performed after the Pap smear.

Indications, particularly with new patients and women younger than 25 y.o. it is appropriate to culture & sensitivity test

for gonorrhea and Chlamydia

using swabs that sample secretions from the endocervical canal.

This step may be performed after the Pap smear.

Tests to Determine OvulationTests to Determine Ovulation

Endometrial biopsy BBT Maturation Index Fern test Spinnbarkheit Test Serum progesterone or urinary progesterone

metabolites levelsdetermination

Endometrial biopsy BBT Maturation Index Fern test Spinnbarkheit Test Serum progesterone or urinary progesterone

metabolites levelsdetermination

Endometrial biopsyEndometrial biopsy

One of the diagnostic tests most frequently performed by gynecologists on an OPD basis.

A rapid, safe, and inexpensive sampling of the endometrial lining is a common procedure in the clinical workup of women with abnormal vaginal bleeding.

One of the diagnostic tests most frequently performed by gynecologists on an OPD basis.

A rapid, safe, and inexpensive sampling of the endometrial lining is a common procedure in the clinical workup of women with abnormal vaginal bleeding.


Indications are: Ovulation and Dysfunctional uterine

bleeding (DUB) demonstrate secretory endometrium

Postmenopausal bleeding To investigate AUB associated with HRT

Chronic uterine infection Demonstrate the classic giant cell &

tubercules i.e. TB

Indications are: Ovulation and Dysfunctional uterine

bleeding (DUB) demonstrate secretory endometrium

Postmenopausal bleeding To investigate AUB associated with HRT

Chronic uterine infection Demonstrate the classic giant cell &

tubercules i.e. TB


Uses instruments that aspirate tissue from the endometrial lining following abrasion or scraping with a small curette or perforated cannula.

Uses instruments that aspirate tissue from the endometrial lining following abrasion or scraping with a small curette or perforated cannula.

Office endometrial aspiration with 3-mm Randall suction curette.


Uses cannulas in that are 2 to 4 mm in diameter and are plastic.

Aspiration of the endometrium is usually accomplished by a syringe.

Uses cannulas in that are 2 to 4 mm in diameter and are plastic.

Aspiration of the endometrium is usually accomplished by a syringe.

Pipelle endometrial suction curette. Note small diameter and flexible nature. Suction is produced by partly withdrawing inner stem.


Pipelle cannula thin, flexible

polypropylene is as effective as rigid instruments in obtaining endometrial specimen

often with less discomfort. instrument of first choice

for endometrial sampling. Other flexible plastic

cannulas are equally effective.

Pipelle cannula thin, flexible

polypropylene is as effective as rigid instruments in obtaining endometrial specimen

often with less discomfort. instrument of first choice

for endometrial sampling. Other flexible plastic

cannulas are equally effective.

Pipelle endometrial suction curette. Note small diameter and flexible nature. Suction is produced by partly withdrawing inner stem.


Contraindications: Profuse bleeding is a relative

contraindication.

Endometrial biopsy should not be performed more than 14 to 16 days after ovulation because of the possibility of interfering with

an early pregnancy.

Contraindications: Profuse bleeding is a relative

contraindication.

Endometrial biopsy should not be performed more than 14 to 16 days after ovulation because of the possibility of interfering with

an early pregnancy.


OPD Procedure It is helpful to explain to

the patient that she will experience uterine cramping during the short time that the biopsy instrument is inside the uterus.

A bimanual examination is performed to note the size of the uterus and direction of the uterine cavity.

OPD Procedure It is helpful to explain to

the patient that she will experience uterine cramping during the short time that the biopsy instrument is inside the uterus.

A bimanual examination is performed to note the size of the uterus and direction of the uterine cavity.


A single-toothed tenaculum used to secure the anterior cervical lip.

The exocervix is then cleaned of mucus and bacteria with an iodine solution prior to sampling.

In abnormal bleeding at least four separate areas

should be abraded.

A single-toothed tenaculum used to secure the anterior cervical lip.

The exocervix is then cleaned of mucus and bacteria with an iodine solution prior to sampling.

In abnormal bleeding at least four separate areas

should be abraded.


Cervical stenosis or spasm. most frequent problem in

performing endometrial sampling.

to obtain pain relief and discomfort & overcome resistance is a paracervical block with 1% lidocaine.

Subsequently, the cervix can be dilated painlessly with narrow metal dilators, and the biopsy can be completed.

Cervical stenosis or spasm. most frequent problem in

performing endometrial sampling.

to obtain pain relief and discomfort & overcome resistance is a paracervical block with 1% lidocaine.

Subsequently, the cervix can be dilated painlessly with narrow metal dilators, and the biopsy can be completed.


Major advantages of the endometrial biopsy over D&C are: convenience and cost savings

The clinical results obtained depend on two factors:1. the patient's acceptance

acceptance is higher with narrow cannulas made of plastic.

2. the physician's skill and perseverance.

Major advantages of the endometrial biopsy over D&C are: convenience and cost savings

The clinical results obtained depend on two factors:1. the patient's acceptance

acceptance is higher with narrow cannulas made of plastic.

2. the physician's skill and perseverance.


Routine preoperative endometrial biopsy in asymptomatic women undergoing hysterectomy:

is an unnecessary procedure does not improve patient care.

Routine preoperative endometrial biopsy in asymptomatic women undergoing hysterectomy:

is an unnecessary procedure does not improve patient care.

…continue next meeting…continue next meeting

2.preventive gynecology

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sample of vaginal discharge

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