Endocervical curettage didn't get adequate sample - next step?

@kristindeann Hello, welcome to Mayo Clinic Connect and to our Gynecological Cancers group. Congratulations on complete remission for the blood cancer that was treated last year.

I recall seeing questions in the past in our group from women who have a stenotic cervix and their gynecologist had difficulty getting an endometrial biopsy. I don't recall seeing a specific question about trying to getting to get an adequate sample with endocervical curettage. We are not medical professionals here at Mayo Clinic Connect however we can and do share our own experiences and provide support to one another.

I needed to do some research before answering your question. This will not be new information for you but I will share some of my results in case others might like to see this information to help them to answer your question.

HPV 16/18 refers to a high risk strain of human papillomavirus (HPV). A woman who tests positive with this strain of HPV is at high risk of developing cervical cancer and so more frequent cervical screenings are recommended which I presume is why your gynecological was trying to obtain a biopsy from a curettage procedure.

American College of Obstetricians and Gynecologists (ACOG) HPV:

-- https://www.acog.org/womens-health/experts-and-stories/the-latest/what-to-think-about-if-you-test-positive-for-hpv

DES daughter refers to the mother who as prescribed the medication, Diethylstilbestrol (DES) from about 1940 to 1970 to prevent miscarriage. It was later learned that the daughters of these women were at high risk for developing health problems particularly for cancer:

National Institutes of Health, Diethylstilbestrol (DES) Exposure and Cancer:

-- https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/des-fact-sheet#what-is-the-cancer-risk-of-people-who-were-exposed-to-des-in-utero

Here is an ongoing Discussion on the topic of DES daughters in Mayo Clinic Connect; Has anyone been exposed to diethylstilbestrol (D.E.S) in utero?

-- https://connect.mayoclinic.org/discussion/diethylstilbestrol-d-e-s/

What alternatives did your gynecologist offer besides trying the same procedure again when she cannot "see" the transformation zone she is trying access for the biopsy? Was this an office procedure? Is it possible to convert to a same-day surgical procedure in which you are under anesthesia similar to a uterine D&C? I'm asking this because if this were me I'd wonder if my doctor had other procedures available to open my cervix. Would you like to talk with your gynecological about prescribing a medication that "softens" and then opens the cervix similar to the medications used for labor and delivery?

Is the gynecologist your regular provider? Would you want to get another opinion from a different gynecologist who might specialize in cases such as yours?

Thanks so much for your reply! I have seen three obgyns about this now.

In May 2024 my HPV test showed my HPV (which I got in 2016 and cleared in 2019) came back due to my leukemia. The dual stain was negative. So, my regular obgyn did a colposcopy in the office in May and was able to find the OS, but said it was too small and flush with the vaginal wall to get in (the rest of the exam was all normal). This was just a couple weeks before I started chemo for my leukemia, so we decided just to do another HPV test in November. But then she did a pap at the November visit instead for some reason, which showed no lesions on the outside but was inconclusive for the endocervical canal. I had another HPV test in March 2025 which was still positive, and the dual stain was inconclusive this time because they didn't get a good sample.

So in May 2025 I got a second opinion from an obgyn who specializes in colposcopy who had successfully done my endocervical curettage in 2018, and but he didn't attempt a curettage because he was not 100% confident that what he saw was the OS (this has happened before where a doctor couldn't find my cervix, it seems to be hit or miss depending maybe on their angle?) and he suggested I go to the OR where they have better ways to get in.

So I had this exam in June 2025 by a third obgyn in the outpatient procedure center under conscious sedation. She specializes in hysterectomy so I know she is confident with surgical procedures. She was able to find the tiny OS and use a scalpel to cut past some tissue that was blocking the opening and get dilators in, but a teaspoon of old clotted blood spilled out that we assume was from a prior exam. The clots had caused the canal to balloon, so the curettage tool was not able to scrape the sides enough and the path report showed most of what she got from the endocevix was acellular material (i.e. blood, but not cervical tissue) with scant amounts of glandular tissue. So it was inadequate. She also did four biopsies she thought she did on the ectocervix, but that showed mostly glandular material with a little bit of squamous, so it is confusing to me where those biopsies were taken. At any rate, the path report showed no dysplasia and the acetic acid test showed no abnormalities.

Her concern is that she doesn't know if they got the transformation zone and she worries they won't be able to in the future. I feel like it was the balloon shape that messed her up and it is unclear if the shape will go back to normal now that the old clotted blood is gone. We talked about a leep and a cone biopsy, but again, she seemed insecure about if they would get the transformational zone.

The main thing that is confusing me is that she says doctors only know they found the TZ if they can stain it and see it visually. But how can any doctor see it inside the canal? I am trying to understand these three procedures (curettage, leep, and cone biopsy) and if doctors always visually see the area and locate the transformation zone before taking a sample or if the pathologist is the one who decides if they got the right tissue.

I could just wait six months and do another HPV test and if it is positive then try another curettage or a leep or a cone biopsy in the OR. Or I could do a hysterectomy, which right now I can't wrap my head around.

I am also wondering how HPV behaves in women with a compromised immune system - does it cause cancer changes faster than in normal women?

Thanks for reading this and for any knowledge you can pass along.

p.s. We talked about the drug that makes the cervix dilate, but they said it can cause complications like bleeding in post-menopausal women (I am 58).