DandCnow.info

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Dilation and Curettage: Current Information

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Doctors' Perspectives

Each of the following five gynecologists: Adolf Gallinat, Paul Indman, Keith Isaacson, Charles March, and Thierry Vancaillie, have reviewed and contributed to the body of this website. These doctors have additionally donated their time and talents to provide the following individual perspectives. The following perspectives are based on each doctor’s extensive experience and expertise in the field of gynecology. It is worth mentioning, that when combined, these five doctors offer over 125 years of experience. All of these doctors are active in directly treating patients, and also in contributing to the profession through researching, presenting, publishing, and teaching in the field of gynecology. These doctors have dedicated their lives to the service of humanity with conscience, humility and dignity. Each of these doctors continuous, selfless contributions are appreciated and recognized on every level: on a local level--as they care for their personal patients’ health and as they directly teach and mentor other doctors, and on a global level--as they contribute to the larger community of their peers toward the advancement of their field, gynecology.

Adolf Gallinat, MD

Dr. Gallinat has been practicing gynecology for thirty-five years. He founded Tagesklinik Altonaer Strasse, a day care clinic for gynecological endoscopy in Hamburg, Germany together with Dr. R.P. Lueken in 1984. He was awarded the MIC III qualification by the AGE (Arbeitsgemeinschaft Endoskopie) which is part of the German Society of Gynecology and Obstetrics (DGGG). In addition, Dr. Gallinat a founding member of the European Society of Hysteroscopy (EUSOH), a member of American Association of Gynecologic Laparoscopists (AAGL) and Geburtshülfliche Gesellschaft zu Hamburg. Over the course of his career, Dr. Gallinat has contributed extensively to research efforts and publications in gynecology; more specifically, he has served as editor, co-editor and author in numerous publications and has contributed to a dozen journals. He continues to lecture nationally and internationally at conferences.

History:

In Europe (and here in Germany) there still exists an old-fashioned, traditional health system. Especially in regards to D&C, one can imagine the difficulties involved in breaking down old structures. But the problem is not only tradition. D&C is one of the first operations in residents training and therefore one of the most common surgeries in gynaecology. In the case of an already diagnosed submucous myoma with recurrent bleeding, the first step is always again a D&C, even though it is unsuccessful and only increases the loss of blood.

The development of minimally invasive surgery in the last decades, and of hysteroscopy in the field of gynaecological surgery, has led to new options in establishing precise diagnosis and efficient therapy.

Indications required for D&C :

It should be emphasized that the indication for D&C is only for diagnostic purposes. A concomitant hysteroscopy is required not to miss intrauterine pathology, for example polyps, myomata or malformations etc. There are only two exceptions:

A polyp can be removed by target curettage after hysteroscopic localisation if specific instruments are not available.

Secondly, in severe life threatening post partum bleeding. Hysteroscopic management is not possible. The operation is performed by using a Bumm’sche (Banjo) curette.

Inaccuracy of blind D&C was already previously described in 1957 by Englund, Ingelman-Sundberg a. Westin (Gynaecologia 143:217).

A proper indication for specific treatment reduces intraoperative as well as late complications.

Evacuation of the uterus for termination of early pregnancy or incomplete miscarriage should only be performed by suction curettage. Even a combination with a blunt curettage does not improve results as we have previously shown in our own study in 1977 (Lueken, Gallinat a. Lindemann, Geburtsh und Frauenheilk 37:776). Only the complications increase. However mechanical curettage is still a common practise.

Hysteroscopy:

Although gynaecological laparoscopy is nowadays well established in most centers, the surgical hysteroscopy is only performed in very few centers.

Operative hysteroscopy has to be divided in rough procedures, for example the treatment of submucous myomata, where the large part of the myoma is located inside the uterine cavity. In this case the resectoscope is used, which is worldwide the golden standard.

For fine dissection like synechiolysis or the reconstruction of the uterine cavity, small diameter hysteroscopes and specific equipment are required. The resectoscope is not appropriate for most of these procedures.

Keeping this in mind, hysteroscopic surgery leads to excellent results with a very low complication rate.

Paul Indman, MD

Dr. Indman is a Clinical Associate Professor at Stanford University and is a staff physician at Good Samaritan Hospital of the Santa Clara Valley. He has helped pioneer techniques in Gynecology and minimally invasive surgery. He is on the National Advisory Board and has served on the Board of Trustees for the American Association of Gynecologic Laparoscopists and on the Board of Directors of the American Society for Colposcopy and Cervical Pathology. Over his thirty year career, he has taught physicians locally, nationally, and internationally, and has published chapters in textbooks on advanced surgical techniques, and in numerous medical journals.

Although the D&C is one of the most common procedures in gynecology, it has been the least studied. As gynecologists, the procedure was passed on from generation to generation without critical analysis.

As residents we were taught to do a “diagnostic” or “therapeutic” D&C, yet it is often not diagnostic and other than in acute hemorrhage, rarely therapeutic. The ability to see inside the uterus with a hysteroscope is just as basic to gynecology as the ability to look into a painful ear is to pediatrics. Numerous studies have shown that many polyps, fibroids, and other problems inside the uterus that are frequently missed during a D&C are easily identified at hysteroscopy. The ability to do diagnostic hysteroscopy in an office setting is as basic to the gynecologist as the ability for a pediatrician to look into an ear without going to the operating room.

This site discusses the risk of intrauterine adhesions caused by D&C. The typical history that I see is a woman having a D&C for retained placenta after delivering a baby, or having a second D&C one to two weeks after a prior D&C left behind placental tissue. These are high risk situations. During these aforementioned scenarios, the risk should be recognized and steps should be taken to reduce the risk of developing adhesions.

Another cause of Asherman’s Syndrome, which is unfortunately becoming more common, is inexpertly or inappropriately done hysteroscopic removal of fibroids.

It is also important to realize, however, that the risk of infertility from a properly done suction curettage for incomplete miscarriage or termination of early pregnancy is very low. There are advantages and disadvantages for both D&C and medical management, and both options should be considered.

Charles March, MD

Dr. March has been a University of Southern California School of Medicine faculty member for thirty-five years, both as a full professor and as Chief of Gynecology. He currently also practices privately, as a Reproductive Endocrinologist, at California Fertility Partners. Over his career, he has written over 100 scientific papers, 80 textbook chapters and has received numerous awards and honors. Most notably and related to the content in this site, is his recognition as “Pioneer in Hysteroscopy” by the American Association of Gynecologic Laparoscopists, for his development of new treatment regimens for patients with septate uteri and those with Asherman’s Syndrome. He has treated over 1200 women with Asherman’s Syndrome since 1974.

Intrauterine adhesion (IUA, Asherman’s Syndrome) formation is a unique medical condition in that it is iatrogenic, that is caused by us physicians. Thus, ironically, the very people who, by the use of our knowledge, training, expertise and caring professionalism, are to help patients by preventing and treating illnesses, in fact cause a condition which had widespread ramifications. These are not careless, incompetent physicians. Rather years of education in the leading universities of the world have taught us that a D&C is a harmless procedure.

The current challenge, one that I and many colleagues have spearheaded for many years, is to erase that faulty training from our memory banks. How is this task to be accomplished? We must develop a healthy respect for this fragile, ever changing structure, the endometrium. Understand that I come not to bury the curette, nor to praise it, but rather to limit its use and to add visualization (direct or indirect) to the D&C:

Based upon the clinical situation, is surgery (versus observation or medical therapy) necessary?
If surgery is necessary, why not use ultrasound or hysteroscopy to guide the removal of uterine contents, using indirect or direct visualization, respectively?
Will the D&C occur at a time when the uterus is especially vulnerable to scar formation, such as in the presence of infection or in a hypoestrogenic environment as occurs after delivery, (especially if the mother breastfeeds) or during the administration of gonadotropin releasing hormone agonist therapy?
Can prophylactic measures prevent or reduce the frequency and/or severity of scar formation after a D&C? These include the administration of estrogen after curettage in order to stimulate endometrial regrowth and/or the placement of a stent (with prophylactic antibiotic coverage) for a few days after surgery in order to keep the raw, freshly traumatized surfaces from remaining in apposition during this critical time. We could recommend that breastfeeding be stopped because it is associated with a prolonged and marked period of estrogen deficiency.

The recommendations outlined above have been derived from my experience of operating on more than 1,200 patients who acquired IUA after surgery. In short, we should recall the admonition which we were given as children when we approached railroad tracks: STOP, LOOK, LISTEN.

Thierry Vancaillie, MD

Dr. Vancaillie, is currently the Head of the Department of Endo-Gynecology, Royal Hospital for Women, Sydney, Australia. He has been practicing gynecology as practitioner, professor and researcher for over 25 years. His publications include over 60 scientific papers and abstracts, 40 textbook chapters, and 3 books including: Manual of Hysteroscopy. Dr. Vancaillie has created advancements in gynecological surgery, for which he holds three patents (and three more patents pending).

Dilation and Curettage: Historical Perspective and Analysis

A D&C in its classical form provided three types of functions to the physician:

Imaging: prior to sonography, the gynaecologist would order an HSG when the need arose to obtain information on the anatomy of the uterus, but in many cases, information would also be gathered by 'feeling' with the curette for the presence for instance of a submucous fibroid.
Sampling for histology: in patients with abnormal bleeding, especially in the peri-menopausal period it is essential to obtain a tissue sample for diagnosis. In many cases, the physician would argue that while sampling, he (in the past it was usually a 'he') would also attempt to remove lesions such as a polyp.
Evacuation of tissue and blood clot with the additional benefit in some cases to obtain homeostasis.

I would also highlight that historically it was important to empty the uterus of its contents as quickly as possible for two reasons:

obtain homeostasis readily (transfusions were very risky and uncommon until about the late 70s)
prevent infections: sepsis due to retained products was often dramatic and carried a high mortality rate in addition to a guarantee to end up infertile.

As a result, it is not too surprising that D&C became one of the most commonly performed operations ever. From the mid 20th century, when surgery became more frequently performed as a result of improved asepsis and anesthetic techniques, a D&C became part of every procedure in women undergoing surgery, with or without a clear indication. Times have changed and we should move on.

Still today however, some colleagues will perform a D&C every time they do a laparoscopy. This is clearly wrong. On the other hand under some circumstances the uterine cavity needs to be emptied of its contents and
therefore a number of D & Cs will need to be performed for the foreseeable future.

I recommend that the 'medieval' D&C be replaced with more appropriate treatment modalities:

imaging: there is no place for the D&C as an imaging technique
sampling: gentler techniques such as the pipelle, or hysteroscopy with directed biopsy are far superior to a blind D&C
evacuation of retained products of conception or blood clot or large polyp. For this purpose D&C will remain a necessary evil and sometimes useful tool for physicians. I would start by making a plea to colleagues for greater respect of the D&C as a procedure to evacuate the uterus and obtain homeostasis or prevent endo-myometritis. The general principles of gentle tissue handling, aseptic conditions, antibiotic prophyllaxis and so on should be observed as stringently as for any other procedure. Greater emphasis should be placed on performing the procedure correctly with achievement of the desired effect, thus avoiding the need for re-intervention.

A few other remarks:

I would like to point out that any manipulation carries the inherent risk of causing scarring and that includes hysteroscopy. It is not uncommon for us surgeons to blame the instrument before the hand using it.
Hysteroscopy is also not indicated in the immediate postpartum or post termination period, as there are too may open vessels within the surgical field, which would rapidly lead to fluid over load, a potentially lethal condition.

We do use estrogen liberally in an effort to prevent intra-uterine scarring, but a prospective study would be nice.