Can a 43-year-old gravida 1 para 0 woman with abnormal uterine bleeding likely due to endometrial hyperplasia and biochemical hypothyroidism (clinically euthyroid) safely undergo dilatation and curettage, and what pre‑operative preparation is needed?

Dilatation and Curettage for Suspected Endometrial Hyperplasia

Yes, this patient can safely undergo D&C, and it is the appropriate diagnostic procedure given her age, abnormal uterine bleeding, and suspected endometrial hyperplasia—provided her hypothyroidism is biochemically and clinically euthyroid with no evidence of thyroid storm. 1, 2

Rationale for D&C in This Clinical Context

D&C with or without hysteroscopy is the guideline-recommended diagnostic procedure for women with suspected endometrial hyperplasia or early endometrial cancer, particularly when fertility preservation is being considered. 1 At 43 years of age with nulliparity (G1P0), this patient may desire future fertility, making accurate histologic diagnosis critical for treatment planning.

Why D&C Is Superior to Office Biopsy

• Office endometrial biopsy (Pipelle/Vabra) has a 10% false-negative rate, requiring fractional D&C under anesthesia when initial sampling is inadequate or non-diagnostic. 2, 3
• D&C is superior to office biopsy for accurate tumor grading, which is essential when considering fertility-sparing treatment for atypical hyperplasia/EIN or grade 1 endometrial cancer. 3
• Hysteroscopy-guided D&C allows direct visualization of the endometrial cavity and targeted biopsy of focal lesions (polyps, submucous fibroids) that blind sampling may miss. 2, 3

Pre-Operative Preparation and Safety Considerations

Thyroid Status Verification

The most critical pre-operative concern is confirming true euthyroid status and excluding subclinical hyperthyroidism or impending thyroid storm. 4

• Obtain current TSH, free T4, and free T3 levels to document biochemical euthyroidism before proceeding. 4
• Assess for clinical signs of hyperthyroidism: tachycardia, tremor, heat intolerance, weight loss, anxiety, or goiter. 4
• Thyroid storm in the setting of D&C for gestational trophoblastic disease has been reported and can cause multi-organ failure; although this patient's indication differs, the principle of thyroid optimization remains paramount. 4
• If any doubt exists about thyroid control, delay the procedure until endocrinology consultation confirms safe anesthetic risk. 4

Standard Pre-Operative Work-Up

Complete the following assessments before D&C: 1

• Pelvic MRI to exclude myometrial invasion and adnexal involvement if fertility-sparing treatment is contemplated. 1
• Transvaginal ultrasound to measure endometrial thickness and identify structural lesions (polyps, fibroids, adenomyosis). 2
• Complete blood count to assess for anemia from chronic bleeding. 1
• Coagulation studies if heavy bleeding or bleeding disorder is suspected. 1
• Liver and renal function tests for anesthetic clearance. 1
• Consider genetic counseling/testing for Lynch syndrome given her age (<50 years) and endometrial pathology risk. 1, 2

Antibiotic Prophylaxis

Routine antibiotic prophylaxis is recommended to prevent post-procedural endometritis, which occurs in 5–20% of cases without prophylaxis. 5

Anesthetic Considerations

General anesthesia or deep sedation is standard for D&C, allowing adequate cervical dilation and thorough curettage without patient discomfort. 3, 5

Intra-Operative Technique

The procedure should include: 1, 3

• Hysteroscopy before curettage to visualize the endometrial cavity and identify focal lesions. 1
• Systematic fractional D&C with separate sampling of endocervical and endometrial tissue. 3
• Ultrasound guidance to reduce risk of uterine perforation, particularly given her prior cesarean delivery (0010 obstetric history suggests one prior pregnancy ending in abortion or ectopic). 5
• Experienced operator: endoscopists performing fewer than 500 procedures have four times higher perforation risk. 3

Post-Operative Pathology Review

Histologic confirmation by a specialist gynaecopathologist is mandatory to distinguish between: 1

• Benign hyperplasia (no atypia)
• Atypical hyperplasia/endometrial intraepithelial neoplasia (EIN) (8–29% progression risk to cancer) 6, 7
• Grade 1 endometrioid endometrial cancer (may be amenable to fertility-sparing treatment) 1

The WHO 2014 classification divides hyperplasia into benign hyperplasia versus atypical hyperplasia/EIN, with the latter requiring definitive treatment. 6

Post-Procedure Surveillance

Monitor for complications: 3, 5

• Excessive bleeding (>2 pads/hour for 2 hours)
• Fever >38°C (suggests endometritis)
• Severe unrelieved abdominal pain (suggests perforation or hematometra)
• Foul-smelling vaginal discharge (suggests retained tissue or infection)

Instruct the patient to report these symptoms immediately. 5

Management Based on Histology

If Atypical Hyperplasia/EIN or Grade 1 Endometrial Cancer Is Confirmed

Fertility-sparing treatment requires: 1

• Referral to a specialized center with gynecologic oncology and reproductive endocrinology expertise. 1
• Pelvic MRI confirmation of disease limited to endometrium without myometrial invasion or adnexal involvement. 1
• Informed consent that fertility-sparing treatment is non-standard and requires close follow-up. 1
• Progestin therapy: medroxyprogesterone acetate (MPA), megestrol acetate (MA), or levonorgestrel-releasing IUD. 1, 8
• Repeat endometrial sampling every 3–6 months during treatment. 1, 7
• Hysterectomy with bilateral salpingo-oophorectomy after childbearing is complete. 1

If Benign Hyperplasia Without Atypia

Cyclic progestin therapy (e.g., medroxyprogesterone acetate 10 mg daily for 12–14 days per month) to reverse hyperplasia. 8

If Negative or Inadequate Specimen

Repeat D&C or hysteroscopy with directed biopsy is mandatory if bleeding persists, given the 10% false-negative rate. 2, 3

Common Pitfalls to Avoid

• Never accept an inadequate or negative biopsy as reassuring in a symptomatic 43-year-old woman—persistent bleeding mandates repeat sampling. 2
• Do not proceed with D&C if thyroid function is not confirmed euthyroid—subclinical hyperthyroidism can precipitate thyroid storm under anesthesia. 4
• Do not delay D&C for empiric hormonal therapy—tissue diagnosis must precede treatment in a woman with risk factors for endometrial cancer. 2
• Ensure specialist gynaecopathologist review of all specimens when fertility preservation is considered—accurate grading determines eligibility for conservative management. 1