When is D&C Indicated Based on Ultrasound Findings?
D&C is indicated when ultrasound shows endometrial thickness >3-4mm in postmenopausal bleeding, when office endometrial biopsy is negative despite persistent symptoms, or when fertility-preserving treatment is being considered for grade 1 endometrial cancer or atypical hyperplasia. 1
Primary Indications for D&C After Ultrasound Evaluation
Postmenopausal Bleeding with Abnormal Ultrasound
- Endometrial thickness >3-4mm on transvaginal ultrasound should prompt endometrial sampling, with D&C serving as the definitive diagnostic step when initial office biopsy is inadequate 1
- The diagnostic pathway should begin with transvaginal ultrasound measurement of endometrial thickness, followed by endometrial sampling, with hysteroscopy as the final step 1
- When ultrasound shows endometrial thickness ≥8mm, hysteroscopy identifies abnormalities in all cases, making D&C under hysteroscopic guidance particularly valuable 2
Failed or Inadequate Office Biopsy
- Office endometrial biopsy has a 10% false-negative rate, requiring fractional D&C under anesthesia when symptoms persist despite negative office biopsy 3
- Pipelle or Vabra devices are highly sensitive (99.6% and 97.1% respectively) for detecting endometrial carcinoma, but D&C remains superior for accurate tumor grading 1
Fertility-Preserving Treatment Planning
- D&C is the optimal method to obtain histologic characteristics when considering conservative management of grade 1 endometrial cancer or atypical hyperplasia in young women desiring fertility 1
- D&C is superior to pipelle biopsy for accuracy of tumor grade assessment in this specific population 1
- This must be followed by expert pathologist review and pelvic MRI to exclude myometrial invasion 1
Clinical Context and Risk Factors
High-Risk Scenarios Requiring D&C
- Prior uterine surgery (cesarean delivery, myomectomy, prior D&C) increases risk of placenta accreta spectrum disorder, making ultrasound evaluation critical before any subsequent D&C procedure 1
- Women with placenta previa and three prior cesarean deliveries have up to 40% risk of placenta accreta spectrum disorder 1
Persistent or Recurrent Bleeding
- Persistent or recurrent abnormal bleeding, even with normal initial biopsy results, warrants D&C for further evaluation 4
- Hysteroscopy-guided D&C helps evaluate for focal lesions like polyps that may be missed on blind curettage 3
Important Caveats and Pitfalls
Diagnostic Limitations
- D&C has only 49.1% sensitivity for endometrial pathologies overall, with particularly poor performance for endometrial polyps (0% detection in one study) 5
- D&C sensitivity varies by pathology: 83.3% for endometrial cancer, 62.5% for hyperplasia, but only 36.8% for disordered proliferative endometrium 5
- Focal lesions like polyps and submucous fibroids are difficult to diagnose by blind D&C, making hysteroscopic guidance essential 2
Operator Experience Matters
- Endoscopists performing fewer than 500 diagnostic procedures are four times more likely to cause uterine perforation 3