Manipal Nurse Sunday Column: Is a clean-out of the womb (D&C) necessary?

The D&C (Dilatation and Curettage) is a small surgical procedure and perhaps one of the most misused. It literally entails opening the mouth of the womb to allow instruments into the uterus to scrape the contents of the uterus.

It is a procedure that may be done in a hospital using general anaesthesia or in a clinic using local anaesthesia, and is fairly minor.

Contrary to popular belief:

The uses of a D&C are quite specific, and it is not a cure for all female complaints. It is useful for the following:

1. To diagnose conditions of the lining of the womb
2. To treat heavy bleeding. In this case, the material removed should be sent for a histopathology examination to the laboratory and at the end of it a pathology report must be provided for the patient.
3. To remove the products of pregnancy for an abortion or after a miscarriage.

A D&C may, therefore, be recommended for:

1. Heavy menstrual bleeding
2. An investigation of infertility
3. The diagnosis of cancer of the womb
4. An embedded Intra-Uterine Contraception Device (the Loop or the Copper-T, com monly called a ‘five-years’ stop’).
5. An abortion
6. A miscarriage
7. Bleeding after menopause or abnormal bleeding while taking hormone replacement for diagnosis of the underlying problem

In all of the above except 4, 5 and 6, a pathology examination should be carried out on the material removed, and a report should be made available to the patient.

The risks from undergoing a D&C are:

– Risks due to anaesthesia
– A reaction to medication
– Risks from bleeding and infection
– Risks due perforation of the uterus. This may occur because it is a blind procedure and the womb may get injured.
– Scarring of the lining (endometrium)

Scarring of the lining of the womb

This occurs particularly when over zealous curettage or scraping of the lining is done, and this scarring may be severe enough to cause the patient to stop menstruating, as the lining of the womb is the tissue that is shed during a menstrual cycle and passes out as menstruation.

Scarring may cause severe pain and an inability to conceive.

Even if the scarring is minor and not severe enough to prevent the woman from seeing her periods or from conceiving, it can still cause the afterbirth of a pregnancy to be implanted at abnormal sites.

Myths and Unrealistic expectations from a D&C

In some countries, women refer to it as a “clean-out” and believe that the womb needs to be cleaned out periodically by a doctor.

– They need to be reassured that the womb gets a monthly clean-out when the lining sheds with a period, and does not need to be physically cleaned out by undergoing a D&C.
– There is no need to have a D&C after the removal of an IUCD. It does not help in any way.
– With heavy periods, a D&C may help to reduce the flow for one or two cycles only,and then the flow will once again be heavy, if medications such as hormones are not started, and a D&C is rarely needed for this purpose.
– A D&C does not by itself help any woman to conceive. The only use of a D&C in infertility is to diagnose hormone problems, and if a D&C is performed on a patient trying to conceive, a histopathology report must be given to the patient detailing the findings.
– Patients with irregular bleeding due to underlying hormone imbalances do not benefit from a D&C as far as regulating their cycles is concerned.

Recovery from a D&C

Normally a patient can resume day-to-day activities the same day. They may have slight vaginal bleeding or cramps for a few days. Pain medication may be used. Tampon use and sexual intercourse is not recommended for a few days.

To summarize, the reasons to perform a D&C are very specific. Although it is a small procedure, the patient may end up with severe problems. The patient should have a clear picture of why this procedure is being recommended to her, and last but not least, except for abortions and miscarriages, the tissue removed must be sent for histopathology and a report from the laboratory should be provided to the patient.

In other words, if a clean-out is done, the scraping should not be discarded as it provides valuable material for diagnosis of what may be the patient’s problem.

A D&C like any other surgical procedure should not be taken lightly and the patient before agreeing to the procedure must ask the care provider the following questions:

1. What is the reason for the D&C?
2. Is there a medical alternative such as hormones?
3. What are the long-term risks and benefits?
4. Is it going to aid in the diagnosis of the problem?
5. Will there be a histopathology report for the material removed?

Once the above questions are answered satisfactorily, the patient can be reasonably assured that the procedure is needed and/or will benefit her health.

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