D&C Does Not Cause Abnormal Uterine Bleeding or Infertility—It Is Used to Diagnose and Treat These Conditions
Dilation and curettage (D&C) is a diagnostic and therapeutic procedure for abnormal uterine bleeding, not a cause of it. However, D&C can lead to complications that may result in endometrial thinning and subsequent infertility, particularly with repeated procedures.
D&C as a Diagnostic Tool, Not a Cause of Bleeding
The evidence clearly positions D&C as a diagnostic intervention for abnormal uterine bleeding rather than its cause:
D&C is used when office endometrial biopsy is insufficient. When a patient has persistent abnormal bleeding and office endometrial biopsy is negative or inadequate, fractional D&C under anesthesia is the next diagnostic step 1, 2.
Endometrial biopsy is now preferred over D&C because it is less invasive, safer, and lower cost for diagnosing endometrial hyperplasia or cancer 3. D&C has limited diagnostic value beyond detecting endometrial cancer 4.
D&C has a false-negative rate of approximately 10% for detecting endometrial pathology 1, which is why it's being replaced by less invasive methods.
Potential Complications: Endometrial Thinning and Infertility Risk
While D&C doesn't cause abnormal bleeding, repeated D&C procedures can cause endometrial thinning, which may lead to infertility:
A 2017 study demonstrated a significant negative correlation between endometrial thickness and number of D&C procedures (P < 0.001). Patients without D&C had mean endometrial thickness of 10.9 ± 2.1 mm, while those with one D&C for spontaneous abortion had 7.9 ± 2.3 mm, and those with ≥2 procedures had 6.9 ± 2.9 mm 5.
Gradual endometrial thinning occurs with repeated procedures, whether performed for spontaneous or induced abortion 5. This thinning can impair implantation and contribute to infertility.
D&C may predispose to postpartum hemorrhage in subsequent pregnancies (P < 0.0004), though it doesn't significantly increase rates of preterm delivery, preeclampsia, placental abruption, or miscarriage 6.
Rare Complication: Post-D&C Arteriovenous Malformation
If a patient presents with repeated abnormal vaginal bleeding after D&C, consider uterine arteriovenous malformation (UAVM) as a diagnosis 7. This is uncommon but can cause life-threatening bleeding. Diagnosis requires Doppler ultrasonography and CT angiography, with treatment via uterine artery embolization.
Other D&C-Related Complications
Long-term complications following endometrial ablation (not D&C specifically) include 3:
- Asherman syndrome (intrauterine adhesions)
- Cervical stenosis
- Endometrial contracture and distortion
- Delayed endometrial cancer diagnosis
The majority of D&C complications occur during cervical dilation 4, emphasizing the importance of careful technique.
Clinical Algorithm
For patients with abnormal uterine bleeding:
- Start with office endometrial biopsy (Pipelle or Vabra device: 99.6% and 97.1% sensitivity) 1
- If negative but symptoms persist → fractional D&C under anesthesia 1, 2
- Consider hysteroscopy if focal lesions (polyps) are suspected 2
For patients with repeated bleeding after D&C:
- Obtain Doppler ultrasonography to evaluate for UAVM 7
- If UAVM confirmed → uterine artery embolization
For infertile patients with history of D&C:
- Measure endometrial thickness 5-7 days after ovulation 5
- If thin endometrium (<7 mm) → consider D&C as contributing factor to infertility
- Limit D&C procedures when possible to preserve endometrial integrity
Key Caveat
The question reverses causality. D&C is performed because of abnormal uterine bleeding (to diagnose its cause), not as a cause of bleeding itself. The exception is when D&C causes complications like endometrial thinning or UAVM, which can then lead to secondary bleeding or infertility issues.