International Journal of Gynecological Pathology

00:1–9, Lippincott Williams & Wilkins, Baltimore

Copyright © 2018 by the International Society of Gynecological Pathologists

Original Article

Canadian Consensus-based and Evidence-based Guidelines for

Benign Endometrial Pathology Reporting in Biopsy Material

Carlos Parra-Herran, M.D., Matthew Cesari, M.D., F.C.R.C.P., Bojana Djordjevic, M.D., F.C.R.C.P.,
Katherine Grondin, M.D., F.C.R.C.P., Mary Kinloch, M.D., F.C.R.C.P., Martin Köbel, M.D., F.C.R.C.P.,
Amrah Pirzada, M.D., Anna Plotkin, M.D., F.C.R.C.P., and C. Blake Gilks, M.D., F.C.R.C.P.

Summary: Standardized terminology has proven benefits in cancer reporting; in contrast,

reporting of benign diagnoses in endometrial biopsy currently lacks such standardization.
Unification and update on the lexicon can provide the structure and consistency needed for
optimal patient care and quality assurance purposes. The Special Interest Group in Gynecologic
Pathology of the Canadian Association of Pathologists-Association Canadienne des
Pathologistes (CAP-ACP) embarked in an initiative to address the current need for consensus
terminology in benign endometrial biopsy pathology reporting. Nine members of the Special
Interest Group developed a guideline for structured diagnosis of benign endometrial pathology
through critical appraisal of the available peer-reviewed literature and joint discussions. The first
version of the document was circulated for feedback to a group of professionals in akin fields,
the CAP-ACP Executive Committee and the CAP-ACP general membership. The final 1-page
document included 17 diagnostic terms comprising the most common benign endometrial
entities, as well as explanatory notes for pathologists. The proposed terminology was
implemented in the practice of 5 pathologists from the group, who applied the guideline to all
benign endometrial biopsies over a 2-wk period. A total of 212 benign endometrial biopsies
were evaluated in this implementation step; the recommended terminology adequately covered
the diagnosis in 203 cases (95.8%). A list of terminology for benign endometrial biopsy
reporting, based on expert consensus and critical appraisal of the available literature, is
presented. On the basis of our results of implementation at multiple centers, the proposed
guideline can successfully cover the large majority of diagnostic scenarios. The document
has the potential to positively impact patient care, promote quality assurance, and facilitate
research initiatives aimed at improving histopathologic assessment of benign endometrium.
Key Words: Endometrial biopsy—Guideline—Endometrium—Structured reporting.

Standardized reporting of endometrial pathology is in the communication of pathologic diagnoses and

essential for adequate clinical management of patients augment system-wide quality improvement programs.
and quality assurance. In this regard, the development Structured pathology reports, supplemented with
of consistent reporting terminology will ensure clarity health data from other sources, are also central to

From the Department of Laboratory Medicine and Pathobiology, University of Toronto and Sunnybrook Health Sciences Centre (C.P.-H.,
M.C., B.D.); Department of Laboratory Medicine and Pathobiology, University of Toronto and Trillium Health Partners (A.P.), Toronto, ON;
Department of Pathology, University Hospital of Quebec (Centre Hospitalier Universitaire de Quebec), Quebec, QC (K.G.); Department of
Pathology and Laboratory Medicine, University of Saskatchewan and Saskatoon City Hospital, Saskatoon, SK (M.K.); Department of Pathology
and Laboratory Medicine, University of Calgary and Arnie Charbonneau Cancer Institute, Calgary, AB (M.K.); Department of Laboratory
Medicine, Memorial University, St John’s, NL (A.P.); and Department of Pathology, University of British Columbia and Vancouver General
Hospital, Vancouver, BC, Canada (C.B.G.).
The authors declare no conflict of interest.
Address correspondence and reprint requests to Carlos Parra-Herran, MD, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room
E4-27a, Toronto, ON, Canada M4N 3M5. E-mail: carlos.parraherran@utoronto.ca.

1 DOI: 10.1097/PGP.0000000000000481

Copyright r 2018 International Society of Gynecological Pathologists

2 C. PARRA-HERRAN ET AL.
population-level quality monitoring, benchmarking,
intervention, and benefit analyses in public health (1).
Standardization of cancer reporting has been addressed
by national and international professional organizations
and is currently performed in surgical resections. In
contrast, reporting of benign pathology diagnoses in
biopsy material currently lacks this level of structure.
Compared with other specimens in surgical pathology,
endometrial biopsy suffers significantly higher rates of
diagnostic discrepancy among pathologists, particularly in
the interpretation of non-neoplastic lesions (2). In addition,
some of the diagnostic terminology has not kept pace with
clinical practice advances, especially in the area of
infertility management. Consequently, updated standard
terminology for endometrial biopsy diagnosis is needed.
The Gynecologic Pathology Interest Group (GPIG) of
the Canadian Association of Pathologists-Association
Canadienne des Pathologistes (CAP-ACP) presents this
document as a guideline to practicing pathologists and
other health care professionals in the interpretation and
reporting of benign endometrial samples. We aim to
provide a comprehensive list of diagnoses with a uniform
and clear terminology accepted by pathologists, gynecol-
ogists and obstetricians, gynecologic oncologists, radia-
tion oncologists, and other professionals. It is not
suggested that this template will work for all benign
cases, but we believe that it will be adequate for reporting
the vast majority of benign endometrial biopsies
encountered in practice.
MATERIALS AND METHODS
GPIG was first introduced to the initiative at the
CAP-ACP annual meeting (Vancouver, BC; July
2016), where members were encouraged to partic-
ipate. Interested pathologists were recruited to form
the guideline review group, which reflected the wide
spectrum of practices across Canada.
The first draft of the guideline was developed by 2
members of the GPIG executive committee (C.P.H. and
C.B.G.) based on a review of the published English
literature (reference books and peer-reviewed journal
articles), and active group discussion. Literature review
for this project consisted of searching in PubMed using the
following search terms for the period 2005 to the present:
“endometrium AND pathology,” “endometrial biopsy,”
“endometrial biopsy AND insufficient,” “endometrial
biopsy AND inadequate,” “endometrial polyp,” “endo-
metrial hyperplasia,” “pathology AND progestin,” “path-
ology AND progesterone receptor modulator,”
“endometritis,” “critical value AND endometrial biopsy,”
“endometrium AND reproducibility.” Papers identified
Int J Gynecol Pathol Vol. 00, No. 00, ’’ 2018
Copyright r 2018 International Society of Gynecological Pathologists
were studied, and the literature review was inclusive of
relevant manuscripts cited in those papers identified.
Subsequently, the guideline draft was distributed to
members of the review group for feedback and further
discussion. The product consisted of a 1-page list of
standardized terminology followed by explanatory notes.
Guideline implementation was carried through applica-
tion to routine endometrial biopsies in the practice of 5
members of the review group (C.P.H., M.C., M.K.I.,
A.P., and C.B.G.) for a period of 2 wk (September 2016).
This step included evaluation of consecutive endome-
trial biopsies in 1 general and 4 subspecialized practices.
Each case was examined by 1 of the 5 pathologists.
Biopsies with malignant or premalignant lesions were
excluded from analysis. Number of cases in which the
guideline was successfully used was recorded, as well as
instances in which the guideline could not be applied
satisfactorily and the diagnosis had to be recorded as
free-text.
Lastly, a second round of review of the guidelines was
reviewed by an interdisciplinary team including gynecol-
ogists, gynecologic oncologists, and radiation oncologists.
Subsequently, the document was reviewed by the CAP-
ACP Cancer Care Advisory Committee and the CAP-
ACP executive committee. Upon approval, the document
was circulated electronically to the CAP-ACP member-
ship for a 30-d comment period (April–May 2017).
Feedback from responders was incorporated into the final
version presented here.
RESULTS
Guideline Development
The 1-page document records the type of procedure,
clinical information, and the final histopathologic diag-
nosis. The guideline includes 17 standardized consensus
diagnostic terms comprising the vast majority of diagnostic
scenarios in benign endometrial pathology. Six of these
contain additional optional lines (see next page). Explan-
atory notes accompany most of the listed terms; they
briefly explain the rationale behind the proposed diag-
noses, their pathologic criteria, and/or their clinical
implications (see section below). These notes are aimed
to the pathologist using this guide. However, the
information contained in them can be used to explain
the diagnosis in the comment section of the surgical
pathology report. Figure 1 depicts examples of the
proposed diagnostic categories.
Guideline Implementation
Of the total of 212 benign endometrial biopsies
evaluated and reported following the consensus guideline,
 GUIDELINES ON BENIGN ENDOMETRIAL BIOPSY REPORTING 3

CANADIAN ASSOCIATION OF PATHOLOGISTS—CONSENSUS GUIDELINES FOR ENDOMETRIAL BIOPSY

REPORTING PART I: BENIGN/NON-NEOPLASTIC DIAGNOSTIC CATEGORIES

1. PROCEDURE
Biopsy Endo-myometrial resection
Curettage Other (specify): _________________
Polypectomy Not specified

2. DIAGNOSIS
Non-diagnostic sample (no endometrial tissue present) (Note A)
Scant fragments of inactive endometrial surface epithelium and/or stroma (suboptimal for histopathological
assessment) (Note B)
Inactive endometrium (Note C)
Atrophic endometrium (Note C)
With cystic change
Proliferative endometrium
Weakly proliferative (Note D) Normal proliferative
Disordered proliferative (Note E)
Secretory endometrium
Normal secretory
Date ___ (Note F)
Irregular secretory (Note G)
Menstrual endometrium (Note H)
Benign endometrium with diffuse stromal breakdown (Note I)
Endometrial polyp(s)
Endometrial hyperplasia without atypia (Note J)
Endometritis (Note K)
Chronic (plasma cell) Granulomatous
Acute
Changes consistent with exogenous hormonal therapy (Note L)
Progestin
Progesterone receptor selective modulator
Products of conception (Note M)
Chorionic villi
Chorionic plate
Chorionic membranes
Implantation site trophoblast
Exaggerated implantation site
Embryonic/fetal tissue

Pregnancy-related endometrial changes (Note N)

Pregnancy-related endometrial changes only; no products of conception identified (Note O)
Placental site nodule / remote implantation site
Adipose tissue, mesothelium – lined tissue or other extrauterine tissues present (Note P)
Other (specify): _______________________

Mandatory items (at least one in each section is required)

Optional items

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4 C. PARRA-HERRAN ET AL.

FIG. 1. (A) Although scant, this sample contains > 10 strips of endometrial epithelium. In a postmenopausal patient, this biopsy can be
considered adequate (3); however, the same sample in a premenopausal woman or with worrisome clinical findings may still represent suboptimal
sampling, and repeat biopsy can be recommended (see Note B). (B) Secretory endometrium clinically diagnosed as endometrial polyp. (C)
Disordered proliferative endometrium (see Note E); patchy stromal breakdown is part of its diagnostic spectrum (inset). (D) Endometrial
hyperplasia without atypia (see Note J). (E) Irregular secretory endometrium with incipient stromal decidualization and dyssynchronous early
secretory phase-glandular changes (see Note G). (F) When diffuse, stromal breakdown can be seen in the context menstrual endometrium,
dysfunctional cycle or cessation of hormonal therapy (see Note I). (G) Endometrium with progesterone receptor selective modulator associated
changes; note the pseudosecretory glandular architecture with mild dilation and absent to abortive cytoplasmic secretions, occasional mitotic
activity, and uniform stroma (see Note L). (H) Endometrial biopsy containing adipose tissue, which should prompt immediate review of the
medical records and communication with the treating physician (see Note P).

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 GUIDELINES ON BENIGN ENDOMETRIAL BIOPSY REPORTING
203 case (95.8%) diagnoses were adequately incorporated
in the recommended terminology. In the remaining 9, the
guideline could not be applied because the final diagnosis
was not fully incorporated into the consensus list (5 cases,
2.3%) or due to the presence of relevant nonendometrial
tissue (4 cases, 1.9%).
EXPLANATORY NOTES
Note A
This term is recommended for inadequate/nondiagnostic
samples, in which an endometrial assessment cannot be
made as the endometrium has not been sampled.
Note B
This term is recommended when endometrial
tissue is present, but is scant and therefore sub-
optimal for evaluation. In postmenopausal women,
an adequate sample should contain at least 10 strips
of endometrium, as defined by Sakhdari et al. (3).
The negative predictive value of a negative biopsy
with <10 strips of endometrium was only 81%,
compared with > 99% for samples with 10 to 30
strips and 100% for samples with > 30 strips (3). In
suboptimal samples, consideration for repeated
sampling can be suggested in the report. Whether a
repeat sampling is undertaken will depend on the
clinical scenario, that is, the hysteroscopic appear-
ance of the endometrium, whether there is persistent
abnormal bleeding, etc.
In premenopausal women, as well as those with
abnormal findings on imaging, the adequacy of moderate
(10–30 strips) or abundant ( > 30 strips) samples should
be established according to the clinical scenario since
even a moderate amount of tissue may be insufficient
(sampling of the lower uterine segment only) (4). If
sample adequacy is a concern, consideration for repeated
sampling can be suggested in the report.
Note C
Inactive endometrium is a generic term for a
spectrum of circumstances in which the endome-
trium is quiescent and lacks proliferative or secre-
tory differentiation (premenarche, pharmacological
effect, postmenopause). “Atrophic endometrium”
refers to the physiologically inactive endometrium
in the context of postmenopause, where there is a
marked decrease in the amount of specialized
endometrial stroma present. When present, cystic
atrophy can be mentioned, since this finding may
correlate with a thick endometrium on imaging.
Copyright r 2018 International Society of Gynecological Pathologists
5
Note D
The term “weakly proliferative endometrium” repre-
sents instances in which a diagnosis of inactive endome-
trium is being entertained, but on high-power examination
rare glandular and/or stromal mitoses are identified, and
thus a diagnosis of inactive endometrium is not tenable.
This term is suggested to separate instances of weak
proliferative activity in postmenopause, which require
reporting and clinical correlation, from the normal
(physiological) proliferative phase endometrium.
Note E
Disordered proliferative endometrium is secondary
to unopposed estrogen stimulation of the endome-
trium, most frequently seen in the context of
anovulation. Other scenarios include obesity and
exogenous estrogen administration. Stimulation re-
sults in variation in glandular size and shape with
dilated, branching or stellate forms, patchy stromal
breakdown and surface repair (5,6). Glandular irreg-
ularity is not associated with significant crowding
(increased gland to stroma ratio). And endometrial
polyp should also be excluded.
Note F
Determination of the “date” in the secretory cycle on a
routine basis is optional. Evidence shows that, while there
is some degree of consistency in the changes observed
during the luteal phase, the traditional histologic criteria
for dating of the endometrium have at most modest
reproducibility (7–9). Dating, however, may be very
occasionally requested by the clinician to document a
normal progression of the luteal phase in the context of
infertility. In these instances, determination of the date, or
at least stage of the secretory phase (early, mid, or late)
may be undertaken.
Note G
The proposed term “irregular secretory endometrium”
applies to benign endometria with secretory change that
does not fit within the physiological progression of
the luteal phase. These include disordered proliferative
endometrium with superimposed ovulation (glandular
secretory change in an architectural disordered back-
ground with variation in gland size and shape akin to
disordered proliferative endometrium) and intrinsic
luteal phase defects (weak or uneven secretory changes
and stromal breakdown) (10). Further distinction is not
mandatory, but can be considered and incorporated in a
comment.
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6 C. PARRA-HERRAN ET AL.
Note H
Endometrium obtained at the time of sampling often
includes an admixture of late secretory endometrium
which has not yet undergone breakdown, or early
proliferative endometrium, as well as the endometrial
tissue showing menstrual-type breakdown.
Note I
Benign endometrium with diffuse nonphysiological
breakdown can be seen in the context of cessation of
exogenous hormonal therapy or after a defect in
normal follicle/corpus luteum progression (11,12). It is
distinguished from menstrual phase endometrium by
the lack of late secretory phase changes.
Note J
The term “endometrial hyperplasia without atypia”
is recommended as per the current World Health
Organization Classification of Tumours of Female
Reproductive Organs, and is equivalent to benign
endometrial hyperplasia (13). It is also secondary to
unopposed estrogen stimulation. The term hyper-
plasia implies gland crowding with gland to stroma
ratio > 1:1. Subclassification as simple or complex is
no longer part of the consensus terminology.
Note K
Clinically relevant inflammation in the endome-
trium (endometritis) can be divided in 3 categories:
 Chronic (plasma cell) endometritis: several to
numerous plasma cells are identified within the
endometrium, accompanied by altered stroma
(fibrotic or edematous) and glandular metaplasia
(mucinous or tubal) (10,14). In isolation, occasional
plasma cells can be seen in other conditions
(endometrial polyp, disordered proliferative endo-
metrium, stromal breakdown) and are not sufficient
for the diagnosis of endometritis (15). The use of
special stains for plasma cells such as CD138
immunohistochemistry and Methyl Green Pyronin
special stain is not recommended (15,16).
 Acute endometritis: it can be divided in gestational
(postpartum) and nongestational. The latter is usually
seen in the setting of acute pelvic inflammatory disease.
Acute endometritis should be considered if the biopsy
contains abundant and confluent acute inflammation,
necrotic debris, and/or microabscesses (10). Correlation
with the clinical presentation is recommended when
considering this diagnosis (postpartum period, vaginal
Int J Gynecol Pathol Vol. 00, No. 00, ’’ 2018
Copyright r 2018 International Society of Gynecological Pathologists
discharge, systemic signs of infection, distention of the
endometrial cavity on imaging). It should be distin-
guished from physiological neutrophilic infiltration of
the endometrium (premenstrual and menstrual phase),
which is less prominent and nonconfluent.
 Granulomatous endometritis is very infrequent
(o0.5%); the differential diagnosis includes prior
C-section or dilation and curettage, tuberculosis
(especially when diffuse), atypical mycobacteria,
fungi, and sarcoidosis (17).
Note L
It is anticipated the biopsies in this category, more so
than any other category, will benefit from a free-text
comment that provides a description of findings and
interpretation of those findings in light of the clinical
setting. Progestins (oral, levonorgestrel-releasing intra-
uterine device) and progesterone-receptor modulators
are associated with characteristic morphologic endo-
metrial patterns which, when observed, should be
reported as consistent with therapy-related change;
with the former there is characteristically stromal
decidual reaction with widely spaced simple glands,
while progesterone-receptor modulator therapy can
result in a range of changes, including cystically dilated,
mitotically inactive glands (18–20). It is beyond the
range of this manuscript to review the full range of
changes of the endometrium associated with exogenous
hormone therapy and the reader is referred to reviews
devoted to this subject (21). Other medications such as
oral contraceptives, unopposed estrogen preparations,
and aromatase inhibitors produce less specific changes
(atrophy, asynchronous patterns, disordered prolifera-
tive endometrium) (22). In these instances, changes
observed can be attributed to exogenous therapy if
history of such is documented on the specimen
requisition or in the medical records.
Note M
Endometrial samples submitted in the context of early
pregnancy require identification of products of concep-
tion. Although not mandatory, listing the different
products of conception may provide useful information
to the clinician about the completeness of the evacuation
procedure. For instance, in cases of elective termination
the presence of chorionic membranes and embryonic
tissues confirms disruption of the gestational sac.
Note N
Pregnancy-related endometrial changes include diffuse
stromal decidualization and persistent glandular secretory
 GUIDELINES ON BENIGN ENDOMETRIAL BIOPSY REPORTING
morphology, collectively known as decidua or decidualized
endometrium (10,12). Hypersecretory change, including
Arias-Stella reaction, is also included within this spectrum.
Note O
Absence of placental or fetal tissues after extensive
sampling raises the possibility of ectopic gestation;
therefore, review of recent imaging and human chorionic
gonadotropin beta levels is advised to determine whether
this possibility is suspected or confirmed. Notification of
the pathologic findings to the clinician is necessary if an
ectopic gestation is clinically unsuspected.
Note P
The presence of serosa, adipose tissue or other
extrauterine tissues suggests uterine perforation at time
of procedure, and a comment to this effect should be
part of the diagnostic report. Given the potential for
life-threatening complications, review of recent clinical
notes is advised to determine whether this possibility is
suspected or known to have occurred. If perforation is
not suspected clinically, immediate communication
with the treating physicians is required.
DISCUSSION
The significance of reporting standardization in
surgical pathology has mostly been evidenced in cancer
reporting. National and international professional organ-
izations including the College of American Pathologists
(23), the International Collaboration on Cancer Report-
ing (24), the CAP-ACP (25), and the Canadian Partner-
ship against Cancer (26), periodically publish consensus
guidelines for reporting of cancer surgical pathology
specimens. Despite this accrual of experience on stand-
ardization of cancer diagnosis, a similar initiative for
diagnosis of benign endometrial biopsies has not been
addressed by any national or international professional
organization in anatomic pathology, and reporting of
benign endometrial pathology in biopsy material does
not follow a periodically updated and revised consensus
guideline format.
The lack of consistency in the wording and
reporting of benign diagnoses may lead to misinter-
pretation by other health care providers and the
patient, potentially resulting in inadequate care.
Misinterpretation is more likely to occur by those
who may not be familiar with individual or institu-
tional reporting styles and lexicon, such as those
outside of the pathologist’s area of practice. In a
recent review of 2408 surgical specimens, Agarwal
Copyright r 2018 International Society of Gynecological Pathologists
7
and Wadhwa (2) found that endometrial biopsies
suffered the highest prevalence of diagnostic interob-
server variation. Further, inconsistencies were more
common in biopsies with non-neoplastic (benign)
findings. Among discrepant cases, 46% were major
(would impact patient management) and 54% were
minor. Major discrepancies have potential impact in
patient care, whereas minor discrepancies may impede
population-level quality monitoring and population-
based research.
Standardization is an effective approach to main-
taining updated and relevant diagnostic terminology.
Therefore, our guideline document may circumvent
the current gap between diagnostic terminology and
clinical practice. For example, many practices
routinely request and perform endometrial dating
despite the fact that current diagnosis and manage-
ment of infertility does not rely on precise dating as
it does not correlate with infertility status (27), and
endometrial biopsy is valid only when an anatomic
abnormality is suspected (eg, polyp) (28,29); yet
dating is still routinely requested and performed in
many practices.
The presented reporting guideline document provides
an update in the definitions and criteria for benign
endometrial diagnoses. When available, the updates
were based on peer-reviewed evidence (evidence-based
approach). The remaining diagnoses, given the lack of
research in the area, were mostly or purely based on
reference books and the experience of the GPIG
members (consensus-based approach). It should be
noted, that none of the diagnostic terms in the guideline
are evidence-based, in the sense of being supported by
level-1 or level-2 evidence. In an era with increasing
emphasis on evidence-based practice and rejection of
those practices based solely on opinion, even expert
opinion, we believe that use of standardized reporting
language is a critical first step in enabling studies that
correlate pathologic findings with patient outcome.
Clinical research in benign endometrial pathology is
relatively scant, which represents a major limitation.
Therefore, we aim to periodically update this guideline
as new literature emerges; likewise, the application of
this consensus terminology will serve as a tool to
facilitate clinical research of benign endometrial disor-
ders by unifying terms for case identification and group
analysis purposes.
A major benefit of standardized structured reporting
is the potential integration of anatomic pathology in
health care quality improvement initiatives at the
institutional, local, regional, and national levels. This
is exemplified by the Bethesda system for reporting of
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8 C. PARRA-HERRAN ET AL.
gynecologic cytology (30). Srigley et al. (31) described 6
levels of reporting complexity, and determined that only
higher levels of reporting structure can fully meet the
needs of a health care system. High levels of reporting
structure include electronic standardized structure data
sets, reporting tools (eg, drop-down menus), and
discrete data fields. In this context, structured and
synoptic cancer reporting has been demonstrated to
impact the completeness and accuracy of pathology
reports and to increase clinician satisfaction compared
with lower levels of reporting such as free narrative text
(32,33). Furthermore, secondary users such as epidemi-
ologists, registries, research organizations, and public
health agencies require consolidated data from large
populations. Accordingly, electronically encoded and
standardized diagnoses can mitigate the burden of
manual coding of pathology reports (1). The impact of
structured reporting on benign specimens has not been
documented yet. Nonetheless, evidence from the long-
standing structured cancer reporting system suggests
potential significant benefits for its use in benign specimens
in terms of diagnostic accuracy, physician satisfaction,
patient care, and multilevel quality improvement. Given
its diversity of findings and challenges in interpretation,
the endometrial biopsy is a perfect candidate to benefit
from standardized structured reporting.
The guideline presented here is intended for practic-
ing pathologists and other health care professionals in
the interpretation and reporting of benign endometrial
samples. Although we do not expect this guideline to
be applicable to all endometrial biopsies encountered
in practice, our internal implementation demonstrated
over 90% applicability success rate for biopsy reporting.
In a minority of cases, a relevant diagnosis will not be
fully represented in the guideline; thus, using “other” or
entering the diagnosis without the use of the template
will be appropriate. It is expected that this guideline will
evolve and improve over time; we do not believe that it
is sufficiently validated to be mandated as a practice
“standard” at the present time, although this could
happen in the future.
It is important to note that proper clinical judgment
should be exercised alongside the use of the guideline
document. For instance, individual biopsies may have
> 1 relevant diagnosis, and they all should be listed in
the report. Furthermore, including the information
provided in the explanatory notes of this document as
a comment in the report is encouraged, as it may
provide useful background information to support the
diagnosis. Lastly, including lesions that are subdiag-
nostic for malignancy but are associated with an
increased risk of endometrial neoplasia is beyond the
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Copyright r 2018 International Society of Gynecological Pathologists
scope of the current document. Such instances include
papillary and mucinous proliferations, necrosis, and
focal gland crowding. These and other premalignant
diagnostic instances will be addressed by the special
interest group in a subsequent document.
In summary, we present a consensus guideline of
diagnostic terms encompassing the majority of benign
conditions observed in endometrial biopsy material.
The guideline was a product of collegial and informed
discussions among expert pathologists and colleagues
from relevant disciplines encompassing a diverse geo-
graphic and practice representation. It is also the
product of review and critical appraisal of the available
peer-reviewed literature, which we hope will expand by
the further use of the guideline. Our document has a
high successful applicability rate and the potential to
advance patient care as well as monitoring and quality
improvement programs at multiple levels of the health
care system. Future expansion of this initiative will be
aimed at including premalignant and malignant diag-
noses in endometrial biopsies.
Acknowledgments: The authors thank Dr Phillip Clement,
MD, FCRCP (University of British Columbia) and Drs R.
Michael Shier, MD, FRCS(C), Stephane Laframboise, MD,
FRCSC, MSc, Lilian Gien, MD, FRCSC, MSc, and Eric
Leung, MD, FRCSC (University of Toronto) for reviewing
and endorsing the guideline.
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