Dilatation and curettage

 

What is it?

Dilatation and curettage (D&C) is a method of taking a sample of the lining of the womb (endometrium) so it can be examined under a microscope. The detailed appearance of the cells of the endometrium can yield useful information to help reach a diagnosis. The operation has become less common in recent years but it remains of great benefit in selected cases.

 

Why is it done?

D&C is done for two reasons, both to do with abnormal vaginal bleeding. The exact reasons for doing a D&C seem to vary around the world, and this area is being researched.

To make a diagnosis

Examination under a microscope of the endometrial tissue removed during a D&C can show how it is responding to the monthly hormone cycle since abnormal hormone levels can change the appearance of this tissue. This is the most common reason for period problems.Over-thickening of the womb lining or a small polyp growing into the cavity of the womb can be diagnosed during a D&C.

Unexpected bleeding after the menopause may rarely be caused by cancer of the endometrium. D&C is a reliable way to check for this. A D&C is occasionally used to investigate infertility as a way of seeing if the endometrium is responding to the normal hormonal cycle.

D&C sometimes has a place in checking the extent of spread of abnormal looking cells (called CIN) of the cervix (neck of the womb),during treatment called a cone biopsy where part of the affected cervix is removed.

In many instances D&C is being replaced as a diagnostic procedure by other procedures, some of which can be done without anaesthetic as an outpatient. One such procedure is something called pipelle biopsy where a small tube like a straw is inserted into the womb and then suction is applied with a syringe as the tube is withdrawn. This sucks samples of the womb lining into the tube, which can then be analysed under the microscope. Adequate samples are obtained in 91% of cases and this does not require an anaesthetic of any kind.

Another means of diagnosing uterine (womb) problems is something called a hysteroscopy which involves looking inside the womb with a special narrow telescope. This is usually performed under a brief general anaesthetic and, depending on what is seen, curettings (samples) can be taken in a way similar to a D&C.

As a treatment

D&C can completely remove and thus treat an endometrial polyp. Sometimes just doing a D&C makes troublesome periods better. It is essential in treating an incomplete miscarriage, and is also done if a contraceptive coil (IUD) gets stuck in the womb.

 

How is it done?

It is done under a general anaesthetic, or a spinal or epidural anaesthetic if a general is not suitable for an individual. The D&C is done through the vagina, and there is no scar. The cervix is made wider than usual (dilatation) to allow a narrow spoon-like scraping instrument (curette) into the womb. The scrapings are collected and sent to the laboratory. The operation itself only takes about five minutes.

What are the risks?

Overall, this is a very safe operation, but like all operations, the anaesthetic has its own particular risks. These can be quite different between individuals, and they should be discussed with the anaesthetist beforehand. The short duration of the operation makes these risks as small as they can be.

All forms of surgery carry a small but recognised risk of excess bleeding and infection, even with the best possible technique. Very rarely the womb is perforated by the curette. This sounds alarming, but usually results only in extending the hospital stay by a day or two for observation. The womb heals readily. Also very rarely it is possible for the cervix to become weakened by the dilatation, potentially leading to problems with miscarriage in women planning future pregnancies.

 

What tests might be done?

  • Before surgery the gynaecologist will ensure that an up-to-date cervical smear result is available, and if not, will suggest doing one.
  • Blood tests
  • Hormone studies may be done shortly before the operation, depending on the reason for the D&C.
  • Anaesthetists like to be sure that anaemia is not present, and a full blood count is likely to be done beforehand. This is particularly relevant when bleeding has been heavy.

What preparations would be helpful?

D&C can easily be done as a day case, and if the patient is fit and healthy and has someone to be around for 24 hours after the operation, then this is the easiest way all round.

If there is any important question over health, or if the patient will be alone, then an overnight stay afterwards may be recommended. If special considerations apply (for instance for diabetic patients), then a stay beforehand as well will be recommended.

In general it is best not to smoke, and if possible, give up altogether at least six weeks before the operation. This reduces the excess anaesthetic risks that smokers carry.

General fitness always aids recovery from anaesthetics and operations, apart from being a good idea anyway.

 

What can be expected on the day?

 For those staying overnight, a mild sedative (premed) may be given by mouth or injection a couple of hours before the operation. It is usual not to give a premed for day case surgery. Mandatory pubic shaves are not necessary for a D&C and are completely outdated. They may not even be suggested.

In the anaesthetic room just outside the operating theatre itself, the anaesthetist will insert a narrow needle into an arm vein, and leave behind a plastic tube with a cap on it. This allows repeated injections to be given without further puncturing the skin. The anaesthetic injection to go to sleep is given this way.

The first awareness afterwards will be in the recovery room, where highly trained staff observe and aid the patient in awakening. This part may be hard to remember later on.

Some women have no pain at all afterwards, but most experience a crampy period-like pain which settles rapidly over the day. There is accompanying bleeding which settles to spotting and stops altogether within a week at most.

What can be expected later on?

General anaesthetics interfere with normal sleep patterns for a day or two after an operation, and it is common to feel unexpectedly tired for several days. This is not unlike jet lag, or the feeling after missing a night's sleep.

If all is well, then it is fine to drive from 24 hours after a general anaesthetic.

It should be possible to return to work within 48 hours. Unless advised differently for some reason, it is fine to resume lovemaking as soon as spotting has stopped.

 

What self-help strategies are there?

  • Ensure maximum fitness before the operation
  • Give up smoking six weeks beforehand
  • A range of complementary medical remedies are available for the treatment of vaginal bleeding. In general, take a GMC registered doctor's advice regarding diagnosis and treatment.
  • Whilst "alternative therapies" are unlikely to cause harm, missing an important diagnosis could have serious consequences. Make a safe choice of approach.
 

Where can I get further information?

Apart from contacting your own GP, the following organisation may be of help:

Women's Health Concern Ltd
Whitehall House
41 Whitehall
London
SW1A 2BY
Telephone: 0845 123 2319
Email: info@womens-health-concerns.org
Website: www.womens-health-concerns.org