dilation and curettage

n. (Abbr. D & C)
A surgical procedure in which the cervix is expanded using a dilator and the uterine lining scraped with a curette, performed for the diagnosis and treatment of various uterine conditions.

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Key Terms: Endomerial hyperplasia, Endometrial polyps, Epidural anesthesia, Hysteroscopy.

Definition

Dilatation and curettage (D&C) is a gynecological procedure in which the lining of the uterus (endometrium) is scraped away.

Purpose

D&C is commonly used to obtain tissue for microscopic evaluation to rule out cancer. The procedure may also be used to diagnose and treat heavy menstrual bleeding and to diagnose endometrial polyps and uterine fibroids. D&C can be used to remove pregnancy tissue after a miscarriage, incomplete abortion, or childbirth, or as an early abortion technique up to 16 weeks. Endometrial polyps may be removed, and sometimes benign uterine tumors (fibroids) may be scraped away.

Description

D&C is usually performed under general anesthesia, although local or epidural anesthesia can also be used. Using local anesthesia reduces risk and costs, but the patient will feel cramping during the procedure. The type of anesthesia used often depends upon the reason for the D&C.

To begin the procedure (which takes only minutes to perform), the doctor inserts an instrument to hold open the vaginal walls, and then stretches the opening of the uterus to the vagina (the cervix). This is done by inserting a series of tapering rods, each thicker than the previous one, or by using other specialized instruments. The process of opening the cervix is called dilation.

Once the cervix is dilated, the physician inserts a spoon-shaped surgical device called a curette into the uterus. The curette is used to scrape away the uterine lining. One or more small tissue samples from the lining of the uterus or the cervical canal are sent for analysis by microscope to check for abnormal cells.

Although simpler, less expensive techniques such as a vacuum aspiration are quickly replacing the D&C as a diagnostic method, it is still often used to diagnose and treat a number of conditions, especially when cancer is suspected.

Preparation

Because opening the cervix can be painful, sedatives may be given before the procedure begins. Deep breathing and other relaxation techniques may help ease cramping during cervical dilation.

Aftercare

A woman who has had a D&C performed in a hospital can usually go home the same day or the next day. Many women experience backache and mild cramps after the procedure, and may pass small blood clots for a day or so. Vaginal staining or bleeding may continue for several weeks.

Most women can resume normal activities almost immediately. Patients 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

The primary risk after the procedure is infection. Signs of infection include:

• fever
• heavy bleeding
• severe cramps
• foul-smelling vaginal discharge A woman should report any of these symptoms to her doctor, who can treat the infection with antibiotics before it becomes serious.

D&C is a surgical operation, which carries certain risks associated with general anesthesia. Rare complications include puncture of the uterus (which usually heals on its own) or puncture of the bowel or bladder (which requires further surgery to repair).

Normal Results

Results are considered normal if no unusual thickening, growths, or cancers are found. Removal of the uterine lining causes no side effects, and may be beneficial if the lining has thickened so much that it causes heavy periods. The uterine lining soon grows again normally, as part of the menstrual cycle.

Abnormal Results

Some types of uterine thickening, called hyperplasia, are considered abnormal. Simple hyperplasia is a benign condition in which the uterine lining becomes thicker and with more endometrial glands. In complex hyperplasia, another condition where the uterine lining has thickened, the endometrial glands are crowded together. In 80% of cases these conditions will improve, and there is little risk of cancer. Only 1% of simple hyperplasia and 3% of complex hyperplasia will become cancerous.

Atypical hyperplasia is a more serious finding. In this type of endometrial thickening, the cells are abnormal. Twenty-nine percent of women with atypical hyperplasia develop cancer. In fact, in 17% to 25% of women with atypical hyperplasia who have a hysterectomy within one month of diagnosis, a carcinoma is found elsewhere in the endometrium.

Questions to Ask the Doctor

• What are you looking for in the D&C?
• Do you recommend any special preparation before the procedure?
• How long will the procedure take?
• What is the risk of finding cancer in my case?
• What action will be taken if cancer is found?
• Will a repeat D& C be necessary?

A D&C is not a fool-proof procedure because only a portion of the uterine lining is sampled. Therefore, it is possible for a cancer to be missed. Because of this, patients with atypical hyperplasia must have another D&C in three or four months. Combining a hysteroscopy (a procedure where a physician can see the lining of the uterus using a special tool) with D&C may increase the accuracy of the diagnosis in some cases. However, this combination is not recommended when endometrial carcinoma is suspected because of the possibility that the hysteroscopy itself can aid in the spread of cancer through the fallopian tubes.

Resources

Books

Berman, Michael L., and Michael T. McHale. "Uterus." In Cancer Treatment, edited by Charles M. Haskell. 5th ed. Philadelphia: W.B. Saunders, 2001, pp. 951-55.

Byers, Lowell J. et al. "Uterus." Clinical Oncology, edited by Abeloff, Martin D. et al., 2nd ed. Philadelphia: Churchill Livingstone, 2000, pp. 1987-97.

Organizations

American College of Obstetricians and Gynecologists. 409 12th St. SW, PO Box 96920, Washington, DC 20090-6920. .

—Carol A. Turkington

For a list of words related to dilation and curettage, see:

• Procedures - dilation and curettage: D and C; scraping tissues of uterus walls by insertion of instrument through widened cervix for diagnosis or abortion

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