What are the indications for a dilation and curettage (D&C) procedure in a female patient of reproductive age with menorrhagia?

Indications for Dilation and Curettage in Menorrhagia

D&C is indicated in menorrhagia when office endometrial biopsy is negative or inadequate yet symptoms persist, when accurate tumor grading is needed for fertility-sparing treatment planning, or when hysteroscopy reveals focal lesions requiring definitive histologic diagnosis. 1, 2

Primary Diagnostic Indications

Failed or Inadequate Office Biopsy

• Office endometrial biopsy has a 10% false-negative rate, making fractional D&C under anesthesia mandatory when initial office sampling is negative but menorrhagia persists. 1, 2, 3
• D&C becomes the definitive diagnostic step when Pipelle or Vabra devices yield insufficient tissue despite their high sensitivity (99.6% and 97.1% respectively) for detecting carcinoma. 2, 4
• Non-diagnostic or inadequate office biopsy results cannot be accepted as reassuring in symptomatic patients and require escalation to D&C. 3, 4

Superior Tumor Grading Accuracy

• D&C is superior to office biopsy methods for accurate tumor grading, which is critical for treatment planning even though office devices detect carcinoma with high sensitivity. 2, 3
• When fertility-sparing treatment is being considered for grade 1 endometrial cancer or atypical hyperplasia in reproductive-age women, D&C with or without hysteroscopy is required for definitive histologic characterization. 1, 2, 3

Hysteroscopy-Guided D&C Indications

Focal Lesion Evaluation

• Hysteroscopy may reveal focal lesions such as polyps in patients with persistent undiagnosed menorrhagia, and D&C provides definitive tissue diagnosis of these lesions. 1, 3
• Research demonstrates that hysteroscopy with directed biopsy is more sensitive than blind D&C alone, leaving only 4 cases undiagnosed versus 21 cases with D&C alone in one comparative study. 5
• However, D&C performed after hysteroscopy does not improve detection of endometrial cancer beyond what hysteroscopy with directed biopsy achieves. 5

Clinical Context and Risk Stratification

High-Risk Populations Requiring Lower Threshold

• Women with risk factors for endometrial cancer (unopposed estrogen exposure, tamoxifen therapy, PCOS, obesity, diabetes, hypertension) warrant more aggressive diagnostic evaluation with D&C when office biopsy is inconclusive. 4
• Patients on tamoxifen who develop menorrhagia require tissue diagnosis before any treatment modifications, as tamoxifen increases endometrial cancer risk (2.20 per 1000 women-years versus 0.71 for placebo). 4

Age-Related Considerations

• In reproductive-age women with menorrhagia, D&C diagnostic yield varies by bleeding pattern: highest in metrorrhagia and postmenopausal bleeding, relatively lower in pure menorrhagia. 6
• Asymptomatic women under age 35 should not undergo routine D&C, as one study found no significant pathology in this group and documented 5 uterine perforations among 222 procedures. 7

Important Caveats and Pitfalls

Operator Experience Matters

• Endoscopists performing fewer than 500 diagnostic procedures are four times more likely to cause uterine perforation. 2, 3
• Prior uterine surgery (cesarean delivery, myomectomy, previous D&C) increases risk of complications and requires careful pre-procedure assessment. 2

Post-Procedure Monitoring

• Watch for excessive bleeding (soaking more than one pad per hour for 2 consecutive hours), fever, or severe unrelieved abdominal pain. 2, 3
• All curetted material must be inspected for completeness and sent for histopathologic examination. 3

When D&C Is NOT Indicated

• Routine screening D&C in asymptomatic average-risk women has no evidence supporting mortality reduction from endometrial cancer. 4
• When transvaginal ultrasound shows endometrial thickness <3-4mm in the appropriate clinical context, office biopsy may suffice before escalating to D&C. 2, 4

Diagnostic Algorithm

1. Initial assessment: Transvaginal ultrasound to measure endometrial thickness and identify structural abnormalities. 2, 4

2. If endometrial thickness ≥3-4mm or structural lesions present: Proceed to office endometrial biopsy (Pipelle/Vabra). 2, 4

3. If office biopsy is negative but symptoms persist: Fractional D&C under anesthesia is mandatory due to 10% false-negative rate. 1, 2, 3

4. If office biopsy is inadequate/non-diagnostic: D&C provides definitive tissue sampling. 2, 3

5. If focal lesions suspected or fertility-sparing treatment considered: Hysteroscopy with D&C for direct visualization and accurate grading. 1, 3