WHAT IS DILATION AND CURETTAGE?

Dilation and Curettage, more known as D&C, is a gynecologic procedure which involves expanding or enlarging the cervix (neck) of a woman’s uterus using a dilator, so that a spoon-shaped metal instrument, called a curette, can lightly scrape or suction away the lining of the uterus for tissue sampling.

EFFECTS OF DILATION AND CURETTAGE

D&C is most commonly performed to:

· Help determine the health of the uterine lining

· Determine if there is an abnormality with the cells that line the endometrium (uterine lining)

· Diagnose and treat abnormal bleeding, and to diagnose endometrial polyps and uterine fibroids.

· Remove diseased tissue or obtain a specimen for diagnostic purposes (i.e. evaluation to rule out cancer)

· Evaluate women who have had abnormal cells appear on their pap smear results.

·  Help determine the degree of abnormality of the endometrium in cases of cancer or pre-cancerous cells detected during a biopsy.

·  Treat or to remove pregnancy tissue after a miscarriage, incomplete abortion, or childbirth.

CANDIDATES FOR DILATION AND CURETTAGE

A D&C is often used for the following conditions:

• Irregular Bleeding -- You may experience irregular bleeding including spotting between periods. If the spotting then develops into a continuous midcycle bleeding, your doctor may perform a D&C to determine the cause.
• Too much bleeding -- Bleeding with long, heavy periods, or bleeding after menopause, can mean a number of problems. These symptoms may not need immediate investigation. At some point, however, your doctor may look for a cause that is best detected with a visual examination of the uterus (hysteroscopy).
• Fibroids and Polyps -- Fibroids are noncancerous growths appearing in and on the uterus causing chronic pain and heavy bleeding. Polyps, like fibroids, are noncancerous growths and are a common cause of irregular bleeding. Polyps and fibroids can have symptoms similar to that of other more serious causes of bleeding. Your doctor may want to perform a hysteroscopy.
• Endometrial Cancer -- A D&C and hysteroscopy are often performed to make sure that your symptoms are not caused by uterine cancer. It is important to detect cancer in its earliest, most curable stages.
• Therapeutic D&C -- A D&C is often planned as treatment when the source of the problem is already known (e.g. incomplete miscarriage or full-term delivery when, for some reason, the uterus has not pushed out all the fetal or placental tissue inside of it. If tissue is left behind, excess bleeding can result which may lead to life–threatening bleeding). Your doctor will want to remove any remaining tissue with a D&C.
• Investigations of Infertility

YOUR CONSULTATION 

Before a D&C, the same general rules for other outpatient procedures apply. Your doctor will most likely see you at least the day before the surgery to discuss the procedure and its potential complications in greater detail. 

·         Avoid unnecessary drugs: A few days before your D&C, you will be asked to stop taking drugs such as aspirin, which can cause increased risk of bleeding, and any over-the-counter medications, such as cold medications and laxatives. Avoid alcohol and cigarette use. You may be advised to stop taking any herbal supplements at least 2 weeks before surgery.

·         Chronic conditions: Your doctor will want your other medical conditions to be under good control before the surgery (e.g. strict hypertension treatment plan). This is important to avoid any unnecessary complications during the procedure.

·         Eating and drinking: Your doctor will also instruct you not to eat or drink for 12 hours before your D&C if it is done under general anesthesia (you will be completely asleep) or for 8 hours before a local or regional (e.g. spinal) anesthesia (only the lower portion of your body is numbed and you will have no sensation) is used.

·         Preliminary tests: On the day before or day of the procedure, your doctor may want to obtain routine blood, urine, and other tests to be sure no problems have been overlooked.

THE PROCEDURE

D&C is performed under general anesthesia, although local or epidural anesthesia may be used. Local anesthesia lessens risks and costs, but you will feel cramping during the procedure. The type of anesthesia used will depend upon the reason for the D&C.

During the procedure, which takes only minutes to perform, you will be positioned on your back and your legs will be placed in stirrups. The doctor will then insert a speculum into your vagina as is done with a pelvic exam to hold open the vaginal walls, and then stretches the opening of the uterus to the vagina (the cervix) by inserting a series of tapering rods, or by using other specialized instruments. This is called dilation.

Once the cervix is dilated, the physician inserts a spoon-shaped surgical device called a curette into the uterus to scrape away the uterine lining. One or more small tissue samples are sent for microscopic analysis to check for abnormal cells. Often, the doctor uses a viewing instrument to examine the uterus visually (hysteroscopy) prior to the D&C to make the procedure more complete.

The entire procedure, including curettage takes about 20-30 minutes.

RECOVERY

After the procedure, you will be cared for in a recovery or post-anesthesia care unit for a few hours to monitor for excessive vaginal bleeding or other complications. This also allows time for recovery from the anesthesia. The procedure is normally very short and the general anesthetic can quickly wear off. You may experience nausea and vomiting, which can be treated with medications.

You can go home soon afterwards. Most hospitals and outpatient clinics will keep you for an hour or until you become fully awake. You will need to arrange for a ride home.

It is advised that you do not drive for at least 24 hours after anesthesia. This is recommended even after a sedative/local anesthesia because these drugs can temporarily impair your coordination and response time.

 You may experience backache and mild cramps after the procedure, and may pass small blood clots for a day or so. Pain relievers are usually given for the cramping, and vaginal staining or bleeding may continue for several weeks. Your next period may be early or late, and may occur within 4 to 6 weeks of the procedure.

You can resume normal activities almost immediately, but should avoid sexual intercourse, douching, and tampon use for at least two weeks to prevent infection while the cervix is closing and to allow the endometrium to heal completely.

RISKS AND COMPLICATIONS

D&C is a commonly performed procedure that is usually very safe and uncomplicated. Yet as with any operation, complications may occur.

Rare complications include puncture of the uterus (which usually heals on its own), puncture of the bowel or bladder (which require further surgery to repair), cervical injuries (from lacerations to the cervix during dilation or curettage), or Asherman Syndrome (formation of scar tissues in the uterus which can cause cessation of menstrual periods and infertility).

The primary risk after the procedure is infection (as instruments are inserted into the uterus) and bleeding and may include signs of:

• Fever (more than 100 F)
• heavy bleeding (more than 6 hours, or requiring a change of sanitary pads several times in 1 hour)
• severe cramps not relieved by ibuprofen or naproxen
• foul-smelling vaginal discharge

A woman should report any of these symptoms to her doctor, who can treat the infection with antibiotics before it gets serious. Most bleeding is rather self-limiting and requires nothing more than oral medications.

FOLLOW UP

The follow up consultation depends on your surgeon. Most doctors have their patients return to the office to make sure that all is well and to discuss the results of the tissue samples that were removed. Your doctor may want to examine you for any signs of infection and to make sure your cervix has returned to normal size. Usually, this is done 2 to 6 weeks post-operatively. You may also be simply notified by a phone call with the results and no direct contact with your health care provider is necessary.

FAQ

What is D&C?

Dilation and curettage (D&C) is a procedure used to diagnose or treat many conditions that cause abnormal bleeding from the uterus. It also can be used to help detect uterine cancer.  

What is the difference between a diagnostic and a therapeutic D&C?

A diagnostic D&C is used to gain information about the uterus to diagnose a medical condition. It is done by obtaining samples of the endometrium to evaluate abnormal uterine bleeding or abnormal cells found during routine screening for cervical cancer. It is usually performed with hysteroscopy; this involves dilating the cervix and inserting a small instrument that allows the physician to examine and photograph the inside of the uterus. This helps the doctor to avoid missing small polyps and ensures that the most visibly abnormal areas are sampled.

In other cases, the procedure is used to treat a medical problem or condition, known as therapeutic D&C. It is done to remove the contents of the uterus in cases as miscarriages, abortions, treatment of molar pregnancies, prolonged or excessive vaginal bleeding and postpartum hemorrhage.

Why is the D&C procedure becoming less common?
This procedure is no longer done to regulate abnormal bleeding patterns in women. Most of these problems are now managed with medications, such as hormones. Ultrasound is playing a greater role in helping to evaluate the uterus without surgery.

In what situations will my health care provider avoid performing D&C?

• Pelvic Infection -- If you have an infection involving your reproductive tract, there is a chance the surgical instruments that will enter the vagina and cervix can carry the bacteria from your vagina or cervix into your uterus. There is also an increased risk of injury to infected tissue. For these reasons, your doctor may prefer to wait until after the infection is cleared up with antibiotics before performing the D&C.
• Blood Clotting Disorders -- Doctors depend on the body's natural ability to clot to stop bleeding after curettage. Women with certain blood disorders are usually not given this during surgery.
• Serious medical Problems -- Heart and lung disease, for example, can make general, and sometimes local, anesthesia risky.

What are some medical issues to consider?

You will be advised to have nothing to eat or drink for at least six to eight hours before the surgery. In some cases, you are given an injection an hour before your operation to make you feel drowsy and help dry up internal fluids. Women younger than 35 years are generally advised against undergoing D&C, unless there is no other alternative.

What are other alternatives to D&C?

                Other forms of treatment depend on the condition. These may include:

• Using a catheter (thin hollow tube) to take a sample of endometrial tissue for diagnostic purposes.
• A hysteroscope (a type of slender telescopic device) is generally advised for taking tissue samples from older women.
• Vaginal ultrasound. This involves introducing a slender device into the vagina to take ‘sound pictures’ of the uterus.
• The oral contraceptive pill can be used to treat heavy menstrual bleeding.

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