Endometrial Sampling/Dilation and Curettage Howard T.
Sharp MD Basics Description Dilation of the cervix and curettage of the endometrium referred to as D!C" is performed to o#tain endometrial tissue in cases of a#normal uterine #leeding$ postmenopausal #leeding$ and a#normal cervical c%tolog% such as a#normal or at%pical glandular cells. Endometrial sampling with small&diameter cannulas ma% also #e performed in the office without the need for dilation of the cervix. Endometrial sampling in the office can #e accomplished #% several devices including' o (lastic cannula with internal piston
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(lastic cannula with s%ringe Stainless steel cannula with a self&contained pump with handle Stainless steel cannula with electric suction
)ndications Endometrial sampling in the office is indicated for diagnosis in the following cases' o *#normal uterine #leeding
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(ostmenopausal #leeding *#normal cervical c%tolog% such as a#normal or at%pical glandular cells
D!C is indicated if endometrial sampling in the office is not possi#le due to'
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Cervical stenosis (atient intolerance )na#ilit% to ade+uatel% access the cervix
*lthough D!C can #e effective as therap% for acute #leeding$ its effect does not provide #enefit in su#se+uent menstrual c%cles.
Site ,ffice$ Surgical Center$ ,-" Endometrial sampling can usuall% #e performed in the office without cervical dilation using a .&mm outer diameter" cannula. /entle dilation ma% #e re+uired and can also usuall% #e performed in the office. This ma% #e assisted #% a paracervical #loc0 see Miscellaneous". D!C is performed in the operating room under general or regional anesthesia. Conscious sedation ma% also #e used. Concurrent (rocedures H%steroscop% is usuall% performed concurrentl% with D!C. This ena#les the surgeon to visuali1e endometrial patholog% if present$ whereas D!C alone is a #lind procedure.
*ge&-elated 2actors (ostmenopausal women have a higher incidence of cervical stenosis$ which can increase the ris0 of uterine perforation during dilation. (ediatric Considerations D!C is rarel% indicated in adolescents with acute menorrhagia. Hormonal management should #e considered 3st$ as li0elihood of endometrial patholog% is small. /eriatric Considerations /eriatric patients are at a higher ris0 of uterine perforation. (regnanc% Considerations Endometrial sampling and D!C are contraindicated in pregnanc%. )n premenopausal women$ hC/ should #e considered prior to EMB/D!C. Epidemiolog% D!C is performed in 45.6/355$555 population$ according to the 3778 surve% of the 9CHS. )t is most commonl% performed in the 38:44&%ear age group. Treatment (rocedure )nformed Consent The patient should understand the potential ris0s and #enefits associated with endometrial sampling/D!C. She should also understand alternatives. (atient Education The patient should have an understanding of the #asic anatom% of the uterus and cervix. -is0s$ Benefits -is0s' o *cute uterine or cervical #leeding
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)nfection of the uterus$ fallopian tu#es$ or urinar% tract ;terine perforation )n<ur% to the intestinal tract
Benefits'
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The a#ilit% to rule out endometrial malignanc% /aining a histologic diagnosis to assist in therap% Therapeutic effect on acute #leeding D!C onl%"
*lternatives 9o treatment ;S of the endometrium=
Sonoh%sterograph%= H%sterosalpingogram= H%steroscop%
Medical
Medical management of a#normal uterine #leeding ma% #e hormonal or nonhormonal see Bleeding$ *#normal ;terine". Surgical (rior to performing endometrial sampling/D!C$ a #imanual exam of the uterus should #e performed prior to the procedure to determine the axis of the uterus. This is done to reduce the ris0 of uterine perforation. Endometrial sampling in the office"'
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This performed with a vaginal speculum in place. Topical lidocaine or a su#mucosal lidocaine in<ection can #e given at the cervix. * tenaculum is placed on the cervix. * cannula is then inserted carefull% to the uterine fundus. Depending on the t%pe of cannula$ an internal piston is pulled$ a s%ringe is aspirated$ or electric suction is applied as the cannula is rotated along the length of the endometrial cavit%.
D!C'
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This is performed under appropriate anesthesia. * weighted speculum is placed vaginall% and a right&angle retractor is used to allow visuali1ation of the cervix. * tenaculum is placed on the anterior cervix. * uterine sound is placed to the uterine fundus and the length of the uterine cavit% is noted. The cervix is then graduall% dilated until a curette can #e inserted to the uterine fundus. This can usuall% #e accomplished with dilation to >:7 mm in diameter. The most common t%pes of dilators are either (ratt or Hegar dilators. (ratt dilators range from 3.:4. 2r. The 2rench unit is 5... mm in diameter. (ratt dilators have a more gradual taper at the ends. The% re+uire less dilating force compared to Hegar dilators. Hegar dilators come in si1es ranging from 3:?> mm and have a #lunter dilating end. Curettage is performed #% appl%ing pressure to the curette handle as the curette is withdrawn from the uterine fundus to the cervix. *n attempt is made to scrape the entire endometrial cavit% in a s%stematic fashion until a @uterine cr%A palpa#le resistance" is noted. The cervix should #e o#served after the tenaculum is removed to assess #leeding$ which ma% re+uire treatment with silver nitrate or a suture.
(.478 2ollowup Most patients will follow&up in the office within wee0s to assess potential earl% complications and to review endometrial histolog%. (rognosis (rognosis after endometrial sampling/D!C is directl% related to histologic findings see chapters on endometrial h%perplasia/endometrial cancer". Complications
The most commonl% occurring late complications associated with endometrial sampling/D!C include endometritis$ salpingitis$ and ;T). Bi#liograph% Crane BM$ et al. ;se of misoprostol #efore h%steroscop%' a s%stematic review. B ,#stet /%naecol Can. ?55>'?6'.C.:.C7. DeSimone C($ et al. -ate of patholog% from at%pical glandular cell (ap tests classified #% the Bethesda ?553 9omenclature. ,#stet /%necol. ?55>D356'3?68: 3?73. Ei HF$ et al. Effect of lidocaine gel application for pain relief during suction termination of first trimester pregnanc%' * randomi1ed controlled trial. Hum -eprod. ?55>'?3'34>3:34>>. Miscellaneous * paracervical #loc0 can #e administered #% in<ecting 8 mE of 3G lidocaine or 5.?8G #upivacaine at the ectocervix at #oth 8 and C oHcloc0. (rior to in<ection$ aspiration of the s%ringe should #e performed to avoid intravascular in<ection. S%non%m s" Endometrial #iops% Clinical (earls I The sharpl% anteverted uterus is at ris0 for a posterior perforation. I The sharpl% retroverted uterus is a ris0 for an anterior perforation. I )n the reproductive&aged woman$ pretreatment with misoprostol can aid in significant cervical preparation/@softeningA and dilation. I )n patients with cervical stenosis$ ;S guidance can #e useful to assess the endocervical canal. I *dolescents who present with acute menorrhagia ma% have a coagulopath%D D!C is rarel% indicated in this age group. *##reviations *;BJ*#normal uterine #leeding D!CJDilation and curettage EMBJEndometrial #iops% hC/JHuman chorionic gonadotropin 9CHSJ9ational Center of Health Statistics Codes )CD7&CM I 863.55 Endometrial #iops% I 863.?5 Dilation ! curettage (atient Teaching (ostprocedure$ the patient should call her ph%sician for heav% #leeding$ fever K355.8L2$ or increased pain.
