Comment on “Endometrial Biopsy Versus No Endometrial Biopsy With a Normal-appearing Cavity During In-office Hysteroscopy for Postmenopausal Bleeding: A Randomized Controlled Trial”

An estimated 10% of individuals with postmenopausal bleeding (PMB) are diagnosed with endometrial cancer, and an effective means of diagnosis is an endometrial biopsy. This method is obviously the best choice when there is a visible abnormality in the endometrium, but when the uterine cavity appears normal, evidence is lacking regarding the benefit of an endometrial biopsy. This study was designed to assess pain levels with endometrial biopsy for patients with PMB and an atrophic-appearing uterine cavity, comparing pain scores for office hysteroscopy with and without endometrial biopsy. This was a single-blinded randomized clinical trial conducted at the Rotunda Hospital in Dublin, Ireland, between September 2022 and February 2024. Inclusion criteria were postmenopausal women (12 months or more of amenorrhea) with PMB and an endometrial thickness of >4 mm or other endometrial abnormality undergoing office hysteroscopy. Exclusion criteria were a uterine lesion requiring biopsy, obvious causes of bleeding from the vagina or cervix, and a personal history of endometrial hyperplasia or cancer. The primary outcome for this study was a pain score as reported on the visual analog scale (VAS). Secondary outcomes included differences in subsequent workups done over the subsequent 6 months. The final analysis included 104 patients, with 169 originally recruited and 65 excluded after randomization due to abnormal hysteroscopy. There were no significant differences at baseline between the 2 groups. VAS pain scores immediately after performance of a hysteroscopy assessment were significantly higher in the biopsy group than in the control group, who had a sham procedure with only the speculum placed ( P <0.0001). Histologic analysis for those in the biopsy group showed benign histology in 57% of patients, with the remaining 43% having insufficient information for diagnosis. In the benign samples, 24% were endometrial polyps, 24% were proliferative endometrium, and 52% were inactive endometrium; no cases of malignancy were reported. These results suggest that endometrial biopsy in patients with PMB and a normal-appearing uterine cavity causes additional pain, potentially with little benefit. Pain represents a large barrier to the completion of in-office hysteroscopy, as well as having an impact on patient satisfaction with the procedure. Consistent with previous studies, this study showed that endometrial biopsy increases the pain patients experience over that from hysteroscopy alone. Pain relief should be offered as part of standard care, and more research should be done to isolate any possible clinical benefits of endometrial biopsy in patients who would be considered lower risk for endometrial cancer based on hysteroscopic findings, which were outside the scope of this study. Future studies should also assess how pain scores and patient satisfaction affect patients’ willingness to undergo a repeat procedure, as some studies have shown that higher pain scores do not necessarily eclipse the convenience of an in-office procedure as opposed to a hospital admission. (Summarized from Tunney E, Yambasu S, Gyawali I, et al. Endometrial biopsy versus no endometrial biopsy with a normal-appearing cavity during in-office hysteroscopy for postmenopausal bleeding: A randomized controlled trial. J Minim Invasive Gynecol. 2025; 32:914-920. doi: 10.1016/j.jmig.2025.07.007)