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Dilatation and Curettage
Treat abnormal uterine bleeding

Dilatation and Curettage (D and C) is a common procedure performed in the United States. It is used as one method to evaluate and treat abnormal uterine bleeding. Dilatation is performed to open and widen the cervix (entrance to the uterus). Curettage is used to sample the endometrium (the lining of the uterus).

Anatomy and Physiology

  • The uterus or womb is a pear shaped organ that is found in the female pelvis at the top of the vagina. It varies in size and shape depending on the hormonal and childbearing status of the woman. The uterus has a cavity, which is closed when the woman is not pregnant (Figures 1 and 2)
  • The inside lining of the uterus, called the endometrium, separates from the uterine wall each month. The vaginal bleeding that occurs is called the menses or period. The menses do not occur during pregnancy and normally continues until the menopause
  • The lowest portion of the uterus at the point that it connects to the vagina contains the neck of the uterus or cervix. The opening in the center of the cervix is the entrance to the uterine cavity
  • The Fallopian tubes are found at the upper end of the uterus. There is one Fallopian tube on each side of the uterus. These hollow tubes allow for the fertilized egg to travel to the uterus
    1. The ovaries lie just beneath the other end of the Fallopian tubes and contain the female's eggs. Each Fallopian tube hangs over the ovary like a hood
    2. When an egg leaves the ovaries, it is directed by the hood into the Fallopian tubes and then through the tubes into the uterus where the egg may implant into the uterine wall
  • There are a series of ligaments that attach the uterus and Fallopian tubes to the pelvic wall. The blood vessels to the uterus and ovaries are contained within these ligaments
  • Lymph nodes are found near the uterus and along the blood vessels of the uterus. Lymph nodes are small glands about the size of a small nut that are part of the lymphatic system. The lymphatic system is found throughout the body and is composed of these nodes connected by thin channels (lymphatics) filled with a colorless fluid called lymph. This system is important since it acts as one of the first defenses against disease
  • In some patients there may occur congenital abnormalities of the uterus including a complete double uterus or a doubling of only parts of the uterus. Sometimes there is only one Fallopian tube
Figure 1 - Anatomy of the uterus and surrounding organs as seen in a section through the middle of the body. © C. ScaliciFigure 2 - Uterus as seen from in front. © C. Scalici

Pathology

  • A D&C is performed on women because of many pathological conditions which can cause abnormal uterine bleeding.
  • Post menopausal bleeding - Uterine bleeding that occurs more than twelve months after a woman's last menstrual period. Of concern is that the bleeding may be the result of uterine cancer
  • Endometrial Hyperplasia - Endometrial hyperplasia occurs when the lining of the uterus grows too much. It is a benign condition. Certain conditions put a woman at risk. These conditions include obesity, infrequent menses, unopposed estrogen, diabetes, and Polycystic Ovary Syndrome (multiple ovarian cysts). Continued growth of the endometrium may lead to endometrial cancer
  • Endometrial Cancer - When the endometrial cells become abnormal, continued growth can become malignant.
  • Dysfunctional Uterine Bleeding - As women begin to age, the correct amount of hormones can be ineffective to produce a regular menstrual cycle. Low amounts of progesterone (a female hormone) frequently cause the bleeding
  • Uterine fibroids - Fibroids occur from the overgrowth of cells from the muscular portion of the uterus. Fibroids can grow next to the lining of the uterus. These are frequently called submucosal fibroids (Figure 3). Abnormal bleeding and cramping can occur
  • Endometrial polyp - Endometrial polyps are growths that develop from the lining of the uterus or cervix. Theses polyps generally are not cancerous
  • Abnormal Pregnancy - These include miscarriage, ectopic pregnancy (pregnancy in a Fallopian tube) or molar pregnancy (grapelike overgrowth of placental tissue). All can lead to abnormal bleeding
Figure 3 - Fibroid tumors in the submucosa (left) and muscle (right) of the uterus. © C. Scalici

History

  • The most common reason for a D&C is abnormal uterine bleeding
  • Abnormal uterine bleeding can occur as women begin to age
  • Menses (period) may become very heavy lasting for over 7 days in duration
  • Bleeding may become irregular with bleeding in between the menstrual cycle
  • Postmenopausal bleeding is abnormal. This may be a sign of uterine cancer
  • Medical or anatomical problems may be the cause of heavy or irregular bleeding
  • Medical conditions such as thyroid disease or bleeding disorders can cause irregularities in the cycle
  • Some women will change their cycle because of the hormonal level change that occurs in perimenopause
  • Other causes of abnormal uterine bleeding include cervical cancer, uterine cancer, uterine fibroids, endometrial polyps, endometrial hyperplasia, ectopic pregnancy or an abnormal pregnancy

Diagnostic Tests

  • Blood Tests - Blood tests such as a pregnancy test, thyroid screen, screening coagulation studies, and hormonal female blood levels are useful
  • Ultrasound - Abdominal ultrasound evaluation is performed by placing a transducer probe on the abdomen. The transducer sends out a signal which is reflected off the organs and returned to the transducer. The contour of the uterus can be determined to find irregularities, such as fibroids. The thickness of the endometrium can also be evaluated
  • Transvaginal ultrasound is performed by placing a transducer probe inside the vagina. The sound waves are able to detect the contour of the cervix, uterus and ovaries with great detail. With transvaginal ultrasound, the endometrial lining may be examined in detail looking for signs of submucosal (below the endometrium) fibroids, endometrial polyps, endometrial hyperplasia (thickening), uterine cancer or abnormal pregnancy. Cervical problems can also be identified such as endocervical (within the cervix) polyps
  • Pap smear - A Pap smear may be used to determine any sign of precancerous or cancerous cells
  • Sonohysterography - Sonohysterography is performed by filling the cervix and uterus with fluid at the same time a ultrasound is used to evaluate the lining inside the uterus. The test is helpful in identifying the endometrium for polyps and submucosal fibroids

Indications/Contraindications

  • A D&C is indicated to determine conditions that cause abnormal bleeding:
    1. Miscarriage
    2. Irregularities in menstrual bleeding
    3. Postmenopausal bleeding
    4. Endometrial polyps
    5. Endometrial hyperplasia
    6. Endometrial cancer
  • D&C is contraindicated in:
    1. Infection of the uterus
    2. Infection of the fallopian tubes

Procedure

  • D & C is a procedure performed for diagnostic and therapeutic purposes. It provides a sample of the tissue in the uterus. This sample can be viewed under a microscope to tell whether cells are abnormal
  • The patient is placed on the operating table in stirrups
  • A gentle pelvic examination is performed to determine the size and location of uterus
  • The vagina and cervix is cleaned with an antiseptic solution
  • A speculum is placed in the vagina and the top portion of the cervix is gently grasped with a straight instrument (Figure 4)
  • Local anesthesia (most commonly lidocaine - see Anesthesia) is used to numb the cervix
  • An instrument called a cervical dilator is placed into the cervical canal. After the smallest dilator is used, successively larger ones are used to dilate the cervix. Care is taken to determine the direction of the cervical canal to prevent perforation of the cervix or uterus (Figure 5)
Figure 4 - Speculum placed in the vagina. The cervix is grasped with a clamp. Note the submucosal fiboid tumor. © C. ScaliciFigure 5 - Dilator is used to dilate the opening in the cervix. © C. Scalici
  • Fractional curettage is performed by gently removing tissue from the cervical canal. This is important in diagnosing cervical and endometrial cancer
  • An instrument then determines the uterine cavity size. After determining the size and location of the uterus, a second curette is placed into the uterine cavity to the top of the uterus. Sampling of tissue is obtained from all four sides of the uterine cavity (Figures 6 and 7)
  • Commonly a gynecologist will place a hysterscope (a video camera on a tube with lenses) within the uterus to evaluate the lining
  • After sampling the endometrium, the instrument is removed from the cervix making sure no active bleeding occurs
  • The tissue taken during the curettage is then evaluated under the microscope by a pathologist
  • The patient is taken to recovery room to recover for a short period of time
  • Suction D&C
    1. When a pregnant patient has a first trimester loss a procedure called suction D&C is performed
    2. Cervical dilation is performed as above
    3. After adequate dilation of the cervix, a suction curette is placed inside the uterus. Suction is then used to remove placental tissue, embryonic tissue, amniotic fluid and blood
    4. A sharp curettage is placed gently into the uterus to identify any further tissue
Figure 6 - A curette is used to scrape out the submucosal fibroid tumor. © C. ScaliciFigure 7 - Close up figure 6. © C. Scalici

Complications

  • There is no surgical procedure that is free of the possibility of complications.
  • As with any surgical procedure there may be a complication of the anesthetic
  • Injury to the cervix with cervical laceration
  • Scarring of endometrial lining
  • Infection of the uterus or fallopian tubes
  • Uterine perforation (hole in the uterus) leading to possible bowel perforation or significant amount of bleeding into the uterus
  • Hemorrhage that may require a blood transfusion
  • Damage to bowel omentum, mesentery, ureter, bladder and fallopian tube
  • In case of significant injury or bleeding, possible need to open the abdomen and the uterine wound sutured
  • Possible need to remove the uterus (hysterectomy)

Care after the procedure

  • After the procedure the patient is taken to the recovery area for a short period of time before leaving for home
  • A patient should plan on having an escort for transport
  • The patient may experience some nausea from the anesthesia
  • Mild uterine cramping may be experienced. The surgeon may prescribe pain medication for the discomfort
  • It is not uncommon to experience vaginal bleeding and discharge for some time
  • Most commonly the patient may resume normal activity after a few days
  • The patient should refrain from placing anything inside the vagina until instructed by the doctor because the cervix has been opened and this may allow bacteria to pass up into the uterus
  • The endometrium will build up within the next month. The next menstrual cycle may not be regular. It may be late or early
  • The patient should inform the doctor if experiencing any of the following:
    1. Fever
    2. Increasing abdominal pain
    3. Heavy vaginal bleeding (greater than a pad per hour)
    4. Foul smelling vaginal discharge