Is emergency Dilatation and Curettage (D&C) indicated for perimenopausal women with severe Abnormal Uterine Bleeding (AUB) and a thickened endometrium?

Emergency D&C for Perimenopausal Severe AUB with Thickened Endometrium

Emergency dilatation and curettage (D&C) should NOT be performed as the first-line diagnostic procedure for perimenopausal women with severe AUB and thickened endometrium; instead, proceed with office-based endometrial sampling or hysteroscopy with directed biopsy, reserving D&C only for cases where these methods are inadequate or when immediate hemostasis is required for life-threatening hemorrhage. 1, 2

Diagnostic Algorithm for Perimenopausal AUB with Thickened Endometrium

Initial Assessment

• Perform transvaginal ultrasound (TVUS) combined with transabdominal ultrasound to measure endometrial thickness and evaluate for focal versus diffuse pathology 3, 2
• In premenopausal/perimenopausal women, there is no validated absolute upper limit for endometrial thickness, as it varies with menstrual cycle phase 2
• Abnormal echogenicity and texture of the endometrium correlate with significant pathology even when thickness appears normal 2

First-Line Tissue Sampling

• Office-based endometrial biopsy using Pipelle or Vabra devices is the recommended first-line diagnostic procedure, with sensitivities of 99.6% and 97.1% respectively for detecting endometrial carcinoma 1, 2
• This approach avoids the risks and costs of operative D&C while providing adequate diagnostic accuracy for diffuse endometrial processes 4

When to Proceed Beyond Office Biopsy

If office-based sampling is inadequate or inconclusive:

• Proceed to sonohysterography to distinguish between focal and diffuse pathology, with sensitivity of 96-100% for assessing endometrial pathology 1, 2
• Hysteroscopy with directed biopsy is preferred over blind D&C for focal lesions, as it allows direct visualization and targeted sampling 5, 2

If focal endometrial abnormality is identified on imaging:

• Hysteroscopy with directed biopsy should be performed rather than blind D&C, as blind sampling techniques may miss focal lesions including polyps 5, 6
• D&C has very low sensitivity (0%) for diagnosing endometrial polyps and only 36.8% sensitivity for disordered proliferative endometrium 6

Critical Pitfalls to Avoid

D&C Limitations

• D&C has been largely replaced by office-based sampling and hysteroscopy in modern gynecologic practice 5
• D&C sensitivity for various pathologies is suboptimal: 62.5% for endometrial hyperplasia, 36.8% for disordered proliferative endometrium, and 0% for endometrial polyps 6
• The complication rate of D&C is 1.4%, which is avoidable with less invasive methods 7

Diagnostic Accuracy Issues

• Outpatient biopsy using Pipelle is only useful if positive and should not be considered definitive if negative when significant endometrial thickening is present 1
• Neither TVUS nor hysteroscopy alone can reliably rule out endometrial cancer (hysteroscopy missed 34.5% of endometrial cancers in one study) 7
• Endometrial cancer can be present even with endometrial thickness ≤5mm (occurred in 7.14% of cases) 7

When Emergency D&C May Be Indicated

Emergency D&C is reserved for:

• Life-threatening hemorrhage requiring immediate hemostasis where medical management has failed and operative intervention is necessary for bleeding control
• Situations where office-based sampling and hysteroscopy are not feasible due to patient factors (severe cervical stenosis, inability to tolerate office procedures)

Management of Severe Bleeding

Hemodynamic Stabilization First

• Address hemodynamic instability with IV fluids, blood products if indicated
• Consider high-dose progestins or tranexamic acid for acute bleeding control before proceeding to tissue diagnosis 2

Tissue Diagnosis Pathway

• Once hemodynamically stable, proceed with office-based endometrial sampling as first-line 1, 2
• If sampling inadequate or focal lesion suspected, hysteroscopy with directed biopsy provides superior diagnostic accuracy compared to blind D&C 5, 6
• Fractional curettage gives diagnosis in 95% of cases when other methods fail, but should not be the initial approach 1

Follow-up Based on Initial Results

If initial sampling is negative but clinical suspicion remains high:

• Consider more extensive sampling or hysteroscopy with directed biopsies given the significant endometrial thickening 1
• Close monitoring with repeat endometrial sampling every 3-6 months if conservative management is pursued 1

If endometrial cancer is diagnosed:

• Staging investigations must be planned by a multidisciplinary team 1
• Follow-up evaluations every 3-4 months for the first 3 years, then every 6 months during years 4-5 1