الفهرس 
Ethical ConsiderationsOnly 14 pages are availabe for public view
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Abstract
Endometrial biopsy is a common procedure for the investigation of many gynecological disorders including abnormal uterine bleeding, postmenopausal bleeding, abnormal cytology and infertility.
The endometrium is the functionally important mucosal lining of the uterus.
Functionally, there are two zones in the endometrium, the functionalis and basalis. The functionalis is the upper half to two thirds that will be sloughed off at the beginning of menstruation, and the basalis is the deeper portion that remains and regenerates the functionalis during first half of the next cycle.
Endometrial assessment by means of biopsy or sampling of endometrial cells is a minimally invasive. The use of this technique is believed to reduce the cost of the diagnostic work-up for abnormal uterine bleeding without reducing accuracy.
The sensitivity of endometrial biopsy for detection of endometrial abnormalities has been reported to be as high as 96%. However, this office-based procedure may miss up 18% of local lesion, including polyps and fibroids, because only small part of endometrium may be sampled at any one time. Although endometrial biopsy has high sensitivity for endometrial carcinoma, its sensitivity for detecting atypical endometrial hyperplasia may be as low as 81%.
Multiple modalities have been developed and implemented for endometrial sampling, including abrading, lavaging, aspirating and brushing.
In 1935, Novak introduced a novel thinner curette, which could be introduced more easily into the uterine cavity without cervical dilatation. The Novak curette was intended to be used as a method for sampling in the office.
The Novak curette, the best known of early endometrial sampling devices, remains a standard to which many newer technologies are compared. As originally described the Novak curette was rigid, reusable, stainless steel and serrated edges.
It was found for biopsy taken by Novak’s curette specificity and senstivity of 75% and for the D & C a senstivity of 63.26% and specificity of 65.30%, being a difference not meaningful for senstivity as for the specificity between both methods (p > 0.01). Both methods are equally useful for the study of endometrial pathology.
Indications of endometrial sampling are Abnormal uterine bleeding,Postmenopausal bleeding, Cancer screening (e.g., hereditary non polyposis colorectal cancer),Detection of precancerous hyperplasia and atypia, Endometrial dating, Follow-up of previously diagnosed endometrial hyperplasia, Evaluation of uterine response to hormone therapy, Evaluation of patient with one year of amenorrhea, Evaluation of infertilityand Abnormal Papanicolaou smear with atypical cells favoring endometrial origin.
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
The ano-rectum and pelvic floor are supplied by sympathetic, parasympathetic and somatic fibers.
The cell bodies of the nerves which innervate the corpus uteri and cervix are located in the dorsal root ganglia of Th10 - L1 segments of the spinal cord and nociceptive impulses are transmitted via their Aδ and C-fibers. These fibers accompany the sympathetic nerves in the inferior, middle and superior hypogastric plexus as well as the aortic plexi. The nociceptive afferents transverse the lumbar and lower thoracic sympathetic chain to the posterior roots of Th10-L1 nerves and establish synaptic contact with the interneurones in the dorsal horn.
Uterine innervation is mainly associated with blood vessels, but many nerve fibers lie free within myometrium and in endometrial stroma.
Nerve fibers in myometrium are non-cycling nerve fibers by consistent same numbers and lengths throughout menstrual cycle as shown in whereas nerve fibers in functionalis are cycling, which fluctuate according to the menstrual cycle: Nerve fibers were absent in early proliferative phase and increased from early to late secretary phase in the concomitantly growing functionalis (Tatsuo Tomita et al., 2014).
Since blood vessels and nerve fibers develop in coordinated patterns, cyclic changes of endometrial arteries of the human endometrium are well documented, with which nerve fibers develop and regress in coordinated patters: A gradual increase in arborization of coiling of spiral arteries during proliferation in ovulatory period and the spiral growths parallel the gradual increase in length and coiling of endometrial glands in post-ovulatory period.
Nerve fibers likely parallel the growth of arteries but do not grow as fast as arteries especially in functionalis due to a slower growth rate of nerve fiber, since growth of endometrial glands and arteries is faster by estrogen effects than relatively slower growing nerve fibers.
The majority of endometrial nerve fibers were non-myelinated small nerves fibers, some of which may correspond to small sensory nerve fibers for transmitting pain.
Most women experience some degree of discomfort and pain during the procedure. Pain may occur during dilation of the cervix for insertion of the catheter and during endometrial biopsy, which further aggravates pain by inducing uterine contraction.
The potential for a painful experience is related to a number of factors that we can call the patient instrumentation interface. It seems obvious that the larger the diameter of the cervical dilator or hysteroscope sheath, the greater the possibility of pain secondary to stretched or otherwise stimulated pain fibers. from the patient perspective, the cervical canal of the uterus of women of reproductive age, who have had vaginal deliveries, is generally larger caliber than that of women who have never pregnant, those who have only Cesarean sections, or those who are many years postmenopausal without estrogen-based hormone replacement therapy. The same can be said of relative dimensions of the vagina and the speculum used to expose the cervix, an overly large speculum in a narrow vagina is likely to elicit discomfort.
This study was done during the period of July 2012 – March 2016 at Ain Shams University Maternity Hospital and EDCU. It looked at the evaluation and comparison of the efficacy of intrauterine lidocaine versus oral etodolac in controlling pain during office endometrial sampling by Novak curette.
One hundred and nineteen of peri and postmenopausal patients who attended gynecology outpatients’ clinics in Ain Shams University Maternity Hospital and EDCU became of history of irregular uterine bleeding, who fulfilled the inclusion criteria and required endometrial biopsy to be taken were recruited and counseled for participation during the period of the study. After their verbal approval they received a questionnaire; this was completed with the help of instructions given by the investigators who was fully aware of the objectives of the study.
A consent was obtained from them and they were randomly assigned for the intake of intrauterine lidocine or oral etodolac or placebo in study (1st group (n=43) They received oral etodolac 300 mg cap and intrauterine normal saline, 2nd group (n=46) They received intrauterine lidocaine 2% and oral placebo cap (vitaferrol cap), 3rd group (control group, n=30) They received oral placebo cap (vitaferrol cap) and intrauterine normal saline).
The pain intensity was measured by the visual analogue scale (VAS), Numeric pain scale.
Feeding catheter “8 f” (2.70 mm in diameter) was inserted into endometrial cavity up to 2-3 cm distal to endocervix. Five ml of 2% lidocain solution or normal saline was instilled slowly through the catheter into uterine cavity according to each group and catheter was drowned after 3 min.
Subjects received 300 mg oral etodolac cap or placebo half an hour before the procedure. Endometrial sampling of all subjects was performed using the NOVAK endometrial sampling device by the investigator. After completion of the procedure, but before speculum was taken out, scoring severity of pain for each patient according to the visual analogue scale (VAS).
We found highly significant difference between the 3 studied groups as regarding numeric scale and VAS in which the highest score was found among the placebo group coming next to it the group receiving oral Etodolac 300 mg cap then the lowest one was the intrauterine Lidocaine HCL 2%.
The intrauterine Lidocaine HCL 2% group was showing significant difference in pre and post-menopausal patient with endometrial thickness ≥5 mm as regarding pain score.
Also there was a significant negative correlation between endometrial thickness and pain score in women receiving an intrauterine Lidocaine HCL 2% in which the patients with endometrial thickness < 5 mm gave high pain score and the patients with endometrial thickness ≥ 5 mm gave low pain score during endometrial biopsy.