Biopsy of the female reproductive organs involves obtaining a small tissue sample from pathological or suspicious areas for pathological examination to confirm a diagnosis, commonly referred to as reproductive organ biopsy. Frequently employed methods for tissue collection include local biopsy, diagnostic cervical conization, diagnostic curettage, and tissue aspiration biopsy.
Biopsy
Vulvar Biopsy
Indications
This is indicated:
- To determine the type of hypopigmentation disorders in the vulva and to exclude malignancy.
- For vulvar growths or ulcers that are unresponsive to treatment.
- For specific vulvar infections such as tuberculosis or condyloma acuminatum.
Contraindications
These include:
- Acute vulvar infections.
- Menstrual period.
Procedure
The patient is positioned in the lithotomy position. After routine disinfection of the vulva and placement of a sterile drape, a local infiltration anesthetic, such as 0.5% lidocaine, is applied to the biopsy site. For small growths, the tissue can be removed with scissors at the stalk or taken using biopsy forceps. For larger lesions, a partial excision may be performed, while smaller lesions require an en bloc excision. The depth of tissue collection and hemostasis after the procedure need to be ensured. The biopsy specimen is fixed in 4% formaldehyde solution before being sent for pathological examination.
Vaginal Biopsy
Indications
These include:
- Vaginal growths or ulcers.
- Specific vaginal infections such as condyloma acuminatum.
- Suspected squamous intraepithelial lesions (SIL) detected during colposcopy.
Contraindications
These include:
- Acute or subacute genital or pelvic inflammatory diseases.
- Menstrual period.
Procedure
The patient is positioned in the lithotomy position. After inserting a vaginal speculum to expose the biopsy site and performing disinfection, suspicious tissue areas are collected using biopsy forceps. If necrosis is present on the tumor surface, tissue from deeper, fresher areas is obtained. Hemostasis is achieved by applying sterile gauze pressure; a sterile gauze strip with a tail may be placed in the vagina for compression, and the patient is advised to remove it after 24 hours. Biopsy specimens are sent for routine pathological examination.
Cervical Biopsy
Indications
These include:
- High-grade squamous intraepithelial lesion (HSIL) or suspected carcinoma as diagnosed by colposcopy.
- Low-grade squamous intraepithelial lesion (LSIL) on colposcopy combined with cytological findings of ASC-H or above, AGC or above, HPV16/18 positivity, insufficient colposcopy examination, or lack of examiner experience.
- Clinically suspicious carcinoma observed on visual examination.
Procedure
The patient is positioned in the lithotomy position. A vaginal speculum is inserted to expose the cervix, which is then cleaned of mucus and secretions with a dry cotton swab and disinfected.
Tissue from the most severe lesion area is collected using biopsy forceps at multiple or single points. Care is taken to ensure the depth of the biopsy includes full-thickness epithelium and some stromal tissue to allow histological assessment.
Endocervical curettage (ECC) is performed when the lesion extends into the cervical canal, cytological findings are AGC or above, or the transformation zone is classified as Type 3.
Hemostasis is achieved by packing the cervix with sterile gauze with a tail, which is removed by the patient after 24 hours.
Precautions
Biopsy should only be performed after treating acute or subacute genital or pelvic inflammatory conditions.
Biopsy is not recommended during the premenstrual period to avoid confusing biopsy-related bleeding with menstruation, delayed wound healing during menstruation, and the risk of endometrial implantation at the biopsy site. In necessary cases, biopsy can be performed during pregnancy.
Endometrial Biopsy
Endometrial biopsy indirectly reflects ovarian function, directly detects endometrial pathology, evaluates uterine development, and assesses the presence of intrauterine and cervical adhesions. It serves as a commonly used diagnostic tool in gynecological practice.
Indications
This is indicated:
- To identify the cause of abnormal uterine bleeding.
- To investigate intrauterine space-occupying lesions detected using imaging techniques.
- To determine the underlying cause of infertility.
- When endometrial atypical glandular cells are suggested by cervical cytology.
Contraindications
These include:
- Acute or subacute genital or pelvic inflammatory conditions.
- Suspected pregnancy.
- Acute severe systemic illness.
- Body temperature >37.5°C.
Timing and Sampling Sites
Ovarian function assessment is typically performed 1–2 days before menstruation or within 6 hours after the onset of menses. Tissues should be collected from both the anterior and posterior uterine walls. If amenorrhea is present and pregnancy has been excluded, sampling may be done at any time.
When hyperplasia of the endometrium is suspected, tissue collection is done 1–2 days before menstruation or within 6 hours after its onset. If abnormal endometrial shedding is suspected, sampling should occur on days 5–7 of the menstrual cycle.
For primary infertility, sampling 1–2 days before menstruation is recommended. Secretory phase endometrium suggests ovulation, while proliferative endometrium indicates anovulation.
If endometrial tuberculosis is suspected, sampling is performed 1 week before menstruation or within 6 hours after its onset. To prevent the spread of tubercular lesions, the patient is treated with streptomycin (0.75 g intramuscularly) and isoniazid (0.3 g orally) daily for 3 days before and 4 days after the procedure.
If endometrial carcinoma is suspected, sampling can be performed at any time.
Procedure
After the patient empties their bladder, they are placed in the lithotomy position, and the size and orientation of the uterus are noted.
Routine vulvar disinfection is performed, and a sterile drape is applied. A vaginal speculum is inserted to expose and disinfect the cervix.
The anterior or posterior lip of the cervix is grasped with cervical forceps, and a uterine sound is used to determine the size and orientation of the uterine cavity.
In cases of intrauterine space-occupying lesions, a targeted biopsy under hysteroscopic guidance is preferred. If unavailable, a specialized biopsy forceps may be used. Alternatively, a small curette can be used to scrape the uterine walls for assessing endometrial function. Collected tissues are fixed in 4% formaldehyde solution and sent for pathological evaluation. Detailed documentation, including the date of the patient’s last menstrual period, should accompany the specimen.
Diagnostic Cervical Conization
Diagnostic cervical conization is a supplementary diagnostic technique performed when cervical biopsy results are inconclusive or when suspicion for disease remains.
Indications
These include:
- High-grade squamous intraepithelial lesions (HSIL), atypical glandular cells favoring neoplasia (AGC-FN), adenocarcinoma in situ (AIS), or carcinoma indicated in cervical cytology, with negative, unsatisfactory, or unremarkable findings on colposcopy-directed biopsy and endocervical curettage (ECC).
- Cytological results of HSIL or higher, with positive HPV16/18, and biopsy results of low-grade squamous intraepithelial lesion (LSIL) or less, for exclusion of HSIL.
- Pathological results of HSIL from cervical biopsy and/or ECC, requiring exclusion of early invasive carcinoma or endocervical lesions.
- Pathological findings of adenocarcinoma in situ from cervical biopsy.
Contraindications
These include:
- Acute or subacute genital or pelvic inflammatory disease.
- Bleeding disorders, such as those associated with hematological conditions.
Procedure
The patient is positioned in the lithotomy position under anesthesia. Routine disinfection of the vulva and vagina is performed, and a sterile drape is applied.
After catheterization, a vaginal speculum is used to expose the cervix, which is then disinfected.
The anterior cervical lip is grasped with cervical forceps and pulled outward. Compound iodine solution is applied to the cervix. For cold knife conization, a circular incision approximately 0.5 cm beyond the iodine-unstained area is made on the surface of the cervix to a depth of about 0.2 cm with a fine knife, including both epithelial and subepithelial tissues. A cone-shaped excision of the cervical tissue is performed at an angle of 30° to 50°, with the depth of the excision extending 1–2.5 cm into the cervical canal depending on the depth of the lesion and its histological type. Following excision, hemostasis is achieved using thermal coagulation or cervical reconstructive sutures, and the cervical canal is inspected. Loop electrosurgical excision procedure (LEEP) can also be used. The electrode size, type, and treatment parameters are selected according to the lesion's size and the cervical volume, avoiding thermal damage that could impair pathological evaluation of the resection margins.
A 12 o’clock orientation marker is placed on the excised specimen, which is then fixed in 4% formaldehyde solution and sent for pathological examination.
Precautions
Electrosurgical or laser knives are not recommended, as they may damage the tissue edges and compromise diagnostic accuracy. Procedures should be scheduled 3–7 days after menstruation ends. Postoperative antibiotics are administered to prevent infection. Follow-up is conducted six weeks after the procedure. Sexual intercourse and bathing in tubs should be avoided for two months postoperatively.
Diagnostic Curettage
Diagnostic curettage, also referred to as "diagnostic D&C," is the most commonly used method for diagnosing intrauterine diseases. Its purpose is to scrape and collect the endometrium and endometrial lesions for biopsy and pathological diagnosis. When concurrent cervical canal disease is suspected, separate curettage of the cervical canal and uterine cavity is performed, referred to as "fractional curettage."
Standard Diagnostic Curettage
Indications
This is indicated:
- To determine the cause of abnormal uterine bleeding or vaginal discharge.
- To assess the type of menstrual disorder.
- To investigate the cause of infertility.
- For suspected endometrial tuberculosis.
- For cases of retained intrauterine tissue or repeated or heavy uterine bleeding, where complete curettage may assist in diagnosis while providing rapid hemostasis.
Contraindications
These include:
- Acute or subacute genital or pelvic inflammatory disease.
- Suspected pregnancy.
- Acute severe systemic illness.
- Body temperature >37.5°C.
Procedure
The steps are similar to those of endometrial biopsy. Anesthesia is generally not required, though analgesics, local anesthesia, or intravenous anesthesia may be considered for patients with a tight cervical os.
Fractional Diagnostic Curettage
During the procedure, uterine cavity depth is not first probed to avoid introducing cervical tissue into the uterine cavity, which may confuse the diagnosis. The cervical canal is scraped circumferentially from the internal os to the external os with a small curette. After replacing the curette, the endometrium is scraped from the uterine cavity. Curetted tissues from the cervical canal and uterine cavity are sent separately for pathological examination.
Indications
This is indicated:
- For abnormal uterine bleeding with suspected endometrial carcinoma.
- For distinguishing between cervical canal carcinoma and endometrial carcinoma.
Precautions During Diagnostic Curettage
Patients with infertility or abnormal uterine bleeding should undergo curettage 1–2 days before menstruation or within 6 hours after menstruation begins to evaluate ovulation or luteal function.
If suspicious cancer tissue is visually observed during fractional curettage, sufficient tissue should be obtained to allow for pathological diagnosis without performing complete curettage to avoid complications such as uterine perforation, bleeding, or cancer dissemination. If no visibly suspicious tissue is found, thorough curettage should be performed to prevent missed diagnoses.
Bleeding, uterine perforation, and infection are the primary complications of curettage. Certain conditions may lead to significant bleeding during curettage; preoperative fluid replacement, blood cross-matching, and preparations for laparotomy should be made. Careful operation is particularly important for patients who are postpartum, postmenopausal, or have uterine malignancies, all of which pose a higher risk of uterine perforation. Vaginal bleeding over an extended period often indicates intrauterine infection, and curettage may exacerbate infection spread; pre- and postoperative antibiotics should be administered with strict adherence to aseptic techniques during the procedure. Postoperatively, patients should avoid sexual intercourse and bathing in tubs for two weeks to prevent infection.
For suspected endometrial tuberculosis, particular attention should be given to curettage of the uterine cornua, as this area has a higher detection rate for tuberculous lesions.
Repeat curettage due to incomplete operation may damage the basal layer of the endometrium or even scrape out myofibrous tissue, resulting in conditions such as endometritis or intrauterine adhesion, potentially leading to amenorrhea. This should be avoided.