Comparison of the Efficacy of Intrauterine Lidocaine versus Oral Etodolac for controlling Pain during Office Endometrial Biopsy

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.