Patient education: Dilation and curettage (D&C) (Beyond the Basics)

DILATION AND CURETTAGE OVERVIEW — Dilation and curettage (D&C) is a procedure in which material from the inside of the uterus is removed. The "dilation" refers to dilation (opening) of the cervix, the lower part of the uterus that opens into the vagina (figure 1). "Curettage" refers to the scraping or removal of tissue lining the uterine cavity (endometrium) with a surgical instrument called a curette.

A D&C procedure may be done for different reasons, including to look for the cause of a problem, such as abnormal uterine bleeding; for treatment of a miscarriage or postpregnancy bleeding; or for first trimester abortion (pregnancy termination).

This topic discusses the reasons for D&C, how to prepare for the procedure, and what to expect afterwards.

REASONS FOR D&C — There are a number of reasons a D&C might be performed. In some cases, the procedure is used to gain information about the uterus to diagnose a medical condition (called a diagnostic D&C). In other cases, the procedure is used to treat a medical problem or condition (called a therapeutic D&C).

Diagnostic D&C — The primary reason for a diagnostic D&C is to obtain and examine samples of the endometrium (lining of the uterus). This may be done because of abnormal uterine bleeding; following abnormal results from a previous endometrial biopsy, test, or imaging study; or, in rare cases, to look for evidence of pregnancy tissue in a person with an early abnormal pregnancy. (See "Patient education: Abnormal uterine bleeding (Beyond the Basics)" and "Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)".)

In most cases, a health care provider will first try to sample the tissue of the uterus with an office procedure called an endometrial biopsy. If an endometrial biopsy is not possible or if not enough tissue is obtained, a D&C may be needed.

Diagnostic D&C is sometimes done in combination with another procedure called hysteroscopy; this involves dilating the cervix and inserting a narrow camera to examine and photograph the inside of the uterus. The images are displayed on a monitor, allowing the physician to directly see the endometrium. This helps the physician to avoid missing any structural findings (eg, polyps or fibroids) that may be inside the uterus and to take a sample of the most visibly abnormal areas.

After diagnostic D&C, a pathologist examines the tissue with a microscope to evaluate for certain conditions such as endometrial polyps, precancer of the lining of the uterus (endometrial hyperplasia), or endometrial (uterine) cancer.

Therapeutic D&C — Therapeutic D&C is done to remove the contents of the uterine cavity in the following circumstances:

Miscarriage — In some miscarriages, the tissues from a pregnancy are passed completely. In other cases, a D&C is needed to remove this tissue or to ensure that all of it has been passed. (See "Patient education: Pregnancy loss (Beyond the Basics)".)

Abortion — A D&C is one method that can be used when a person chooses to terminate (end) a pregnancy. (See "Patient education: Abortion (pregnancy termination) (Beyond the Basics)".)

Treatment of molar pregnancy — A molar pregnancy is an abnormal pregnancy in which a tumor forms in place of normal placenta. D&C is the standard treatment for molar pregnancy.

Retained pregnancy tissue — A D&C may be recommended for management of bleeding or to identify and remove retained (unpassed) pregnancy or placental tissue following miscarriage, abortion, or delivery.

Prolonged or excessive vaginal bleeding — A D&C may be done as a treatment in some cases of prolonged or excessive uterine bleeding that do not respond to medical treatment. (See "Patient education: Abnormal uterine bleeding (Beyond the Basics)".)

PREPARING FOR D&C — Some patients will need to have blood testing before D&C (such as a blood count or tests of clotting factors), although this is not always necessary. You should not eat or drink anything starting the night before the procedure. You will need someone to accompany you home because it will not be safe to drive after receiving sedation or anesthesia.

After arriving for the procedure, a nurse may place an intravenous line (IV), which can be used to give fluids and medicine before, during, and after the procedure. The nurse or doctor will review your medical history, list of medications used, and any drug allergies.

D&C PROCEDURE — A D&C can be performed in an operating room in a hospital, in an outpatient clinic, or in an outpatient surgery center. Your blood pressure, pulse, and blood oxygen levels are monitored during the procedure. The procedure itself typically takes only 15 to 30 minutes to complete.

Anesthesia — The procedure can be done using general, regional, or local block anesthesia. The type of anesthesia chosen depends upon the reason for the procedure as well as your medical history.

CARE AFTER D&C — After the procedure, you will rest for some period of time in a recovery or post-anesthesia care area. This is necessary to monitor for excessive vaginal bleeding or other complications and allows time for you to recover from any anesthesia you may have received. How long you stay in the recovery area typically depends on what type of anesthesia you had and may range from 30 minutes to a few hours. If you were given general anesthesia, you may have nausea and vomiting, which can be treated with medications.

Recovery at home — You should be able to resume most regular activities within a day or two. Mild cramping and spotting may occur for a few hours or days; cramping can be treated with nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Advil, Motrin) or naproxen (Aleve). You should not put anything inside the vagina (tampons, douches) during this time and should ask when you can safely have sexual intercourse. If you have not yet gone through menopause, your next menstrual period usually occurs within two to six weeks of the procedure, depending on the reason why the D&C was performed.

When to call for help — You should call your provider if you develop fever (temperature greater than 101°F), cramps lasting longer than 48 hours, increasing rather than decreasing pain, prolonged or heavy bleeding, or foul-smelling vaginal discharge.

D&C COMPLICATIONS — D&C is a commonly performed procedure that is usually very safe. As with any operation, complications can occur. Potential complications of D&C include:

Uterine perforation — A uterine perforation is when one of the surgical instruments makes a hole in the uterus. It is more common when the procedure is done during or just after pregnancy since the uterine wall is softened by pregnancy.

Fortunately, most uterine perforations heal on their own and do not require any treatment. Two potential problems caused by perforation are bleeding from injury to a blood vessel and injury to other internal organs. A second procedure or surgery may be needed to look for and potentially repair these types of injuries.

Cervical injury — Injuries to the cervix can occur during dilation or from the curette itself. Lacerations (cuts) to the cervix are managed with pressure to the area, application of medications that help stop bleeding, or, in some cases, stitches or a balloon to hold pressure on the cervix.

Bleeding — It is uncommon to have excessive bleeding or require a transfusion following a D&C. Call your doctor or go to the emergency department right away if you fully soak through two or more pads or tampons in two hours and are still bleeding.

Infection — Infection from a D&C is rare. If you have a fever, pain that is getting worse instead of better, or foul-smelling vaginal discharge after a D&C, contact your doctor's office.

Intrauterine adhesions — Adhesions (areas of scar tissue) can form in the uterus following D&C in rare cases. Adhesions occur most commonly when there is also a uterine infection and the D&C is performed during or after pregnancy. In some cases, this can lead to abnormalities in the menstrual cycle or problems with future pregnancies.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Dilation and curettage (D&C) (The Basics)
Patient education: Uterine cancer (The Basics)
Patient education: Abortion (The Basics)
Patient education: Pregnancy loss (The Basics)
Patient education: Coping after pregnancy loss (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Abnormal uterine bleeding (Beyond the Basics)
Patient education: Endometrial cancer diagnosis, staging, and surgical treatment (Beyond the Basics)
Patient education: Pregnancy loss (Beyond the Basics)
Patient education: Abortion (pregnancy termination) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management
Dilation and curettage
Endometrial sampling procedures
Overview of the evaluation of the endometrium for malignant or premalignant disease
First-trimester pregnancy termination: Medication abortion
Causes of female genital tract bleeding
Overview of pregnancy termination
First-trimester pregnancy termination: Uterine aspiration
Approach to the patient with postmenopausal uterine bleeding
Hydatidiform mole: Treatment and follow-up
Overview of postpartum hemorrhage
Intrauterine adhesions: Clinical manifestation and diagnosis
Overview of second-trimester pregnancy termination
Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●The Mayo Clinic

(www.mayoclinic.com)

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ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dale W. Stovall, MD, who contributed to an earlier version of this topic review.