Why is a Dilation and Curettage (D&C) necessary?

Dilation and Curettage (D&C) Indications and Necessity

A Dilation and Curettage (D&C) is necessary when an office endometrial biopsy is negative but a patient remains symptomatic with abnormal vaginal bleeding, as office biopsies have a false-negative rate of approximately 10%. 1

Primary Indications for D&C

• Following negative office biopsy in symptomatic patients

  • When a patient has abnormal vaginal bleeding (especially postmenopausal) but the office endometrial biopsy is negative or insufficient for diagnosis 1
  • Office endometrial biopsies have a 10% false-negative rate, making follow-up D&C essential for accurate diagnosis 1

• Insufficient tissue from office biopsy

  • When initial sampling doesn't provide adequate tissue for diagnosis (occurs in approximately 22% of cases) 2
  • Follow-up is critical as 2% of patients with insufficient initial samples are later found to have uterine malignancy 2

• Persistent or recurrent undiagnosed bleeding

  • When a patient continues to have unexplained bleeding despite initial evaluation 1
  • May be combined with hysteroscopy to evaluate for lesions such as polyps 1

Diagnostic Accuracy Considerations

• Superior grading accuracy

  • D&C is more accurate (77%) than office endometrial biopsy (58%) in correctly identifying the final tumor grade in endometrial cancer 3
  • D&C is less likely to undergrade tumors (10%) compared to office biopsies (26%) 3

• Detection of endometrial cancer

  • While D&C is more accurate than office biopsy alone, it still has limitations:
  • 30% of patients with complex atypical endometrial hyperplasia diagnosed by D&C are found to have cancer at hysterectomy 4
  • 18% of patients still have invasive cancer found at hysterectomy even after D&C 4

When Hysteroscopy Should Be Combined with D&C

• Visualization of focal lesions

  • Hysteroscopy with directed biopsy is more sensitive in detecting uterine lesions than D&C alone 5
  • Particularly useful for evaluating endometrial polyps or focal abnormalities 1

• Persistent bleeding with normal imaging

  • When transvaginal ultrasound is normal but bleeding persists 6, 7
  • Neither transvaginal ultrasound nor hysteroscopy alone is sufficient to rule out endometrial cancer 7

Pitfalls and Caveats

• D&C alone is not 100% sensitive for detecting endometrial cancer
• Even after a negative D&C, continued monitoring is necessary if symptoms persist
• In patients with high suspicion for endometrial cancer, additional evaluation methods should be considered
• For women with Lynch syndrome, yearly endometrial biopsy is recommended for cancer surveillance, but D&C may be needed for more definitive evaluation 1, 6

Remember that 90% of endometrial cancer patients present with abnormal vaginal bleeding, making thorough evaluation critical for early detection and improved outcomes 1, 6.