Dilation and Curettage (D&C) Procedure
Dilation and curettage (D&C) is a surgical procedure involving cervical dilation followed by scraping or suctioning of the uterine cavity lining to obtain tissue for diagnostic evaluation or therapeutic management of abnormal uterine bleeding, retained products of conception, or suspected endometrial pathology. 1
Procedure Components
The D&C procedure consists of two main steps:
- Dilation: The cervix is gradually dilated using progressively larger dilators to allow instrument access to the uterine cavity 1
- Curettage: The endometrial lining is scraped using a curette or removed via suction to obtain tissue samples for histopathologic examination 1, 2
Primary Clinical Indications
Diagnostic Applications
D&C serves as a diagnostic tool in the following scenarios:
- Abnormal uterine bleeding evaluation: Particularly in postmenopausal women where 90% of endometrial cancer cases present with this symptom 3, 1
- Endometrial cancer diagnosis: When office endometrial biopsy is negative but symptoms persist (given the 10% false-negative rate of office biopsies) 3, 1
- Fertility-sparing evaluation: D&C with or without hysteroscopy is required for patients with atypical hyperplasia or grade 1 endometrioid endometrial cancer who desire fertility preservation 1
- Suspected cervical involvement: Cervical biopsy or D&C is indicated when gross cervical involvement is suspected in endometrial carcinoma 1
Therapeutic Applications
D&C is used therapeutically for:
- Management of retained products of conception after miscarriage, though this requires careful consideration of timing 4, 5
- Treatment of cesarean scar pregnancy when combined with uterine artery embolization 5
Modern Diagnostic Alternatives
Office-based procedures have largely replaced hospital D&C for routine diagnostic purposes:
- Pipelle or Vabra endometrial sampling devices demonstrate extremely high sensitivity (99.6% and 97.1% respectively) for detecting endometrial carcinoma 1, 3
- Office hysteroscopy with suction curettage provides superior diagnostic accuracy compared to traditional D&C while being more convenient, safer, and less expensive 2
- Hysteroscopy should be reserved as the final diagnostic step when endometrial sampling and transvaginal ultrasound are inconclusive 1, 3
Critical Timing Considerations
A significant caveat exists regarding D&C timing in reproductive contexts:
- Six-month recovery period is required after D&C for miscarriage management before attempting frozen embryo transfer, as endometrial function remains compromised during this interval 4
- Live birth rates are significantly higher (relative risk 1.65) when embryo transfer occurs >6 months post-D&C compared to ≤6 months 4
- Endometrial thickness does not reliably reflect functional recovery, as thickness may appear normal while reproductive function remains impaired 4
Procedural Modifications
Endocervical curettage (ECC) prior to endometrial curettage:
- Should NOT be routinely performed when the indication is other than abnormal uterine bleeding, as it yields the highest rate of non-diagnostic specimens (11.59%) without revealing abnormal pathology in these cases 6
- May be considered specifically when abnormal uterine bleeding is the primary indication 6
Pathologic Assessment Requirements
When D&C is performed for endometrial cancer evaluation, the pathologic assessment must include: 1
- Ratio of myometrial invasion depth to total myometrial thickness
- Cervical stromal or glandular involvement
- Tumor size and location (fundus versus lower uterine segment)
- Histologic subtype with grade
- Lymphovascular space invasion
- Peritoneal cytology when applicable
Risk Profile
D&C is not an innocuous procedure and carries surgical and anesthetic risks that must be weighed against diagnostic benefit 7, 2