Dilatation And Curettage (D&C;)

Definition

Dilatation and curettage, also called a D&C;, is a surgical procedure in which the cervix of the uterus is dilated (expanded) and the endometrial lining of the uterus is scraped with a curette (a loop-, ring-, or scoop-shaped instrument with a long, rodlike handle.)

Description

Dilation and Curettage (D&C;) is a very common surgical operation performed on many women each year. It is often used to diagnose or treat abnormal bleeding from the uterus. It can also provide important information about whether a woman has cancer of the uterus.

Dilation means stretching the opening of the cervix with special instruments to make it wider. Once the opening of the cervix is enlarged, another instrument is inserted into the uterus to loosen and remove the lining of the uterus. This is called curettage. It can be done with an instrument called a curette, or by suction applied through a tube, called suction curettage. After a D&C; is performed, a new lining will build up in the uterus during the next menstrual cycle.

A D&C; is often done when a woman has heavy or prolonged menstrual periods or bleeding between periods. These menstrual irregularities have many different causes, one of which is hormone imbalance. Hormone imbalance leads to a thickening of the lining of the uterus and sometimes causes irregular or prolonged bleeding. This condition can occur at any age, but is more common in young women just starting to menstruate and older women before menopause.

Bleeding from the uterus can also be caused by certain types of growths, most of which are not cancerous. Polyps are growths that are attached by a stem or stalk usually to the lining of the uterus or to the cervix. Those inside the uterus can usually be removed by a D&C.; Leiomyomas (fibroids) are tumors that grow from the cells that make up the uterine muscle. They are rarely cancerous. Although they can cause bleeding and cramping, there are often no symptoms. A doctor can detect some of these tumors with D&C;, but another operation may have to be done to remove the tumor.

Bleeding may also be a sign of cancer of the endometrium. Women over age 40 have a higher risk of endometrial cancer. A D&C; or another procedure, called endometrial biopsy, is often performed when a woman over 40 has abnormal vaginal bleeding, especially after menopause.

Procedure

A D&C; is a brief operation. First the doctor carefully examines the reproductive organs in the pelvic area of the body for any unusual changes. Then the walls of the vagina are separated with a speculum, as in a routine vaginal exam, so the doctor can see the cervix. The cervix is held in place with an instrument similar to a clamp. To dilate the cervix, a series of tapered rods of increasing widths are inserted into the opening of the cervix. Under the pressure of these rods, the walls of the cervix are gently widened. An instrument called a curette is then passed into the uterus. This instrument is used to scrape the walls of the uterus. Pieces of the lining of the uterus are loosened and removed. These will be sent to a laboratory to be examined under a microscope. A sample of the lining can also be removed from the uterus by applying suction through a slender tube.

Risks

What are the risks? First any surgery using general anesthesia carries some risks that range in severity from the mild discomfort of nausea to the possibility of cardiac arrest and death. In addition, several complications are specific to the D&C;:

• Perforation of the wall of the uterus is not rare. The uterus is an internal organ that must be explored from an external opening. Thus the operating field is necessarily limited, and the surgeon cannot view the site of the surgery, the uterus itself. The operation is risky because the instruments used to perform the procedure - cervical dilators to enlarge the opening and curettes to spoon out the contents - are sharp and relatively pointed. Women who subsequently undergo abdominal surgery are sometimes found to have uterine scars indicating that an unrecognized perforation had taken place. Although perforation may not cause major after-effects, any accidental entry into the abdominal cavity is a potentially serious event. Infection, internal bleeding, and damage to the bladder and intestine can occur.

• Excessive bleeding is another hazard of a D&C.; When bleeding cannot be controlled by any other means, an emergency hysterectomy must be performed. Though rare, to a woman who has not fulfilled her reproductive desires, it is an especially unfortunate consequence of this "minor" surgery.

• Infection is a risk of any invasive procedure. In young women, infection can damage the fallopian tubes, which are critical for pregnancy and childbearing.

• Scarring of the uterine lining, an infrequently occurring problem known as Asherman's syndrome, is another result of repeated or overly vigorous D&Cs.;

Alternatives

Depending on the reason D&C; is being considered, an endometrial biopsy or a vacuum scraping procedure may be reasonable options.

Endometrial biopsy is commonly used in evaluating fertility problems or bleeding problems experienced by young women when the main goal is to assess the hormone response of the uterine lining. Endometrial biopsy is like a miniature D&C.; Little or no cervical dilation is required and the curette or scraper that is used is very narrow so it can pass through the undilated cervical canal. It is possible in most cases to obtain a few shreds of uterine lining satisfactory for microscopic evaluation using this technique.

A local anesthetic to temporarily block nerves in the cervix and the base of the uterus is commonly used for endometrial biopsy. The anesthetic, however, does not completely eliminate pain, and fairly intense cramping during each scrape is likely. Extensive or thorough scraping, therefore may not be possible.

Vacuum scraping with a local anesthetic is also feasible as an office procedure. Instead of a metal curette, a slender plastic tube attached to a vacuum is inserted through the cervical canal and scraped along the uterine lining to obtain the strands of lining tissue needed. Several types of vacuum equipment are available for this purpose; some use vacuum created by an electric vacuum pump and some use a large, hand-held syringe as a vacuum source. Vacuum probably permits a more thorough scraping of the lining surface with less discomfort than endometrial biopsy, and is more comparable to D&C; in its goals. Studies of vacuum scraping accuracy show that it is comparable to D&C; in its ability to detect uterine cancer, but may not be as useful in detecting and removing uterine lining polyps.

The choice between endometrial biopsy, vacuum scraping, and D&C; with anesthesia depends on your feelings about possible discomfort and anesthesia risk, as well as financial and medical considerations. D&C; is essentially painless with general anesthesia, but may cost as much as $1,000 more than office procedure options. General anesthesia also involves greater risk than local anesthesia, and complication rates after D&C; from bleeding, infection, and perforation are somewhat higher than rates after an office vacuum procedure or endometrial biopsy.

Neither D&C; nor vacuum scraping can provide absolute assurance that uterine cancer is not present. They are among the best techniques available, but small areas of abnormal lining could be missed. If bleeding problems persist after an initial D&C; or vacuum procedure, follow-up and further evaluation will be essential. The procedure may need to be repeated periodically until your problems are resolved.

Questions to Ask Your Doctor

What is the purpose of a D&C;?

How is the procedure performed?

Will it detect fibroids, polyps, or cancer?

Are there any risks involved?

Will a biopsy be done?

Will you use an anesthetic?

Is there any alternative to D&C;?

Will this procedure affect my ability to get pregnant in the future?