When is dilatation and curettage indicated in women (reproductive‑age or postmenopausal), what are its contraindications, and how should it be prepared for, performed, and followed up?

Dilatation and Curettage: Indications, Contraindications, and Management

Indications for D&C

D&C is indicated when office endometrial biopsy is inadequate, non-diagnostic, or negative despite persistent symptoms, particularly in postmenopausal women with bleeding or perimenopausal women with risk factors for endometrial cancer. 1

Primary Diagnostic Indications

• Postmenopausal bleeding with endometrial thickness ≥3-4 mm on transvaginal ultrasound warrants endometrial sampling; when office biopsy (Pipelle/Vabra) fails to provide adequate tissue, D&C becomes the definitive diagnostic step 1, 2

• Persistent or recurrent abnormal bleeding after negative office biopsy requires fractional D&C under anesthesia, given the 10% false-negative rate of office sampling 1, 2

• Premenopausal women ≥45 years with abnormal uterine bleeding should undergo endometrial sampling regardless of ultrasound findings; D&C is performed when office methods are inadequate 2

• Fertility-sparing treatment planning for grade 1 endometrial cancer or atypical hyperplasia in young women requires D&C for accurate tumor grading, as it is superior to Pipelle biopsy for this purpose 1

Specific Clinical Scenarios

• Tamoxifen users with postmenopausal bleeding require tissue diagnosis before any treatment modifications; D&C is indicated when office sampling is inadequate 2

• Lynch syndrome carriers with any abnormal bleeding warrant immediate endometrial evaluation, escalating to D&C if office biopsy is non-diagnostic 2

• Atypical glandular cells on Pap smear in women ≥35 years require endometrial biopsy; D&C follows if office sampling fails 2

• Persistent gestational trophoblastic disease (hCG plateau for 4 consecutive values over 3 weeks or rising >10% for 3 values over 2 weeks) may require repeat D&C, which has a 68% success rate in avoiding chemotherapy when urinary hCG is <1,500 IU/L 3

Hysteroscopy-Guided D&C: The Superior Approach

Hysteroscopy with directed biopsy is more sensitive than blind D&C for detecting all types of uterine lesions and should be the preferred method when available. 4

• Hysteroscopy left only 4 cases of endometrial pathology undiagnosed versus 21 cases missed by blind D&C in a study of 734 perimenopausal women 4

• Focal lesions such as polyps are frequently missed by blind D&C; hysteroscopy allows direct visualization and targeted sampling 1, 4

• Curettage performed after hysteroscopy with directed biopsy does not improve detection of endometrial cancer 4

• Saline infusion sonohysterography should precede hysteroscopy when focal lesions are suspected, providing 96-100% sensitivity for endometrial pathology 2

Contraindications and High-Risk Situations

Absolute Contraindications

• Active pelvic infection (endometritis, cervicitis, pelvic inflammatory disease) requires treatment before elective D&C 1

• Suspected ectopic pregnancy mandates alternative management 2

Relative Contraindications and Risk Factors

• Prior uterine surgery (cesarean delivery, myomectomy, prior D&C) increases risk of placenta accreta spectrum disorder in future pregnancies; ultrasound evaluation is critical before any D&C 1

• Women with placenta previa and three prior cesarean deliveries have up to 40% risk of placenta accreta spectrum disorder 1

• Coagulopathy or anticoagulation requires correction or bridging protocols before elective procedures 1

Pre-Procedure Preparation

Diagnostic Work-Up

• Transvaginal ultrasound combined with transabdominal imaging is the mandatory first step to measure endometrial thickness, identify structural abnormalities, and assess for placenta accreta risk factors 1, 2

• Office endometrial biopsy should be attempted first unless contraindicated; Pipelle has 99.6% sensitivity and Vabra has 97.1% sensitivity for detecting endometrial carcinoma when adequate tissue is obtained 1, 2

• Pregnancy must be excluded with urine or serum β-hCG before any uterine instrumentation 2

Patient Counseling

• Inform patients that D&C has a 5.9% discordance rate for histological subtype and 10.9% for tumor grade compared to final hysterectomy pathology, which may result in under- or overtreatment 5

• Discuss the risk of uterine perforation, which is four times higher when performed by endoscopists with fewer than 500 diagnostic procedures 1

• Explain that office sampling has a 10% false-negative rate, justifying the need for D&C under anesthesia when symptoms persist 1, 2

Anesthesia and Setting

• D&C requires general anesthesia or deep sedation and should be performed in an operating room or ambulatory surgical center 1

• Hysteroscopy-guided D&C is preferred over blind curettage when expertise and equipment are available 1, 4

Procedure Technique

Fractional D&C Protocol

• Perform cervical curettage first (endocervical sampling) before dilating the cervix to avoid contamination of endometrial samples with cervical tissue 1

• Dilate the cervix progressively using graduated dilators to accommodate the curette 1

• Systematically curette all four walls of the uterine cavity (anterior, posterior, and lateral) to maximize tissue yield 1

• Submit endocervical and endometrial specimens separately for pathologic examination to distinguish cervical from uterine pathology 1

Hysteroscopy-Guided Technique

• Direct visualization allows targeted biopsy of suspicious areas and simultaneous removal of polyps or focal lesions 1, 2

• Hysteroscopy has the highest diagnostic accuracy for endometrial cancer and should be considered the gold standard when persistent bleeding follows negative office biopsy 2

Post-Procedure Monitoring and Follow-Up

Immediate Post-Operative Care

• Monitor for excessive bleeding (soaking through more than one pad per hour for 2 consecutive hours), which requires immediate medical attention 3

• Watch for severe abdominal pain unrelieved by prescribed medication, which may indicate uterine perforation or infection 3

• Check for fever >100.4°F (38°C), which suggests infection 3

Warning Signs Requiring Urgent Evaluation

• Large blood clots (larger than a quarter) may indicate incomplete evacuation or uterine atony 3

• Foul-smelling vaginal discharge with increasing pelvic tenderness and fever forms the classic triad of post-procedural endometritis 3

• Syncope or dizziness may indicate significant blood loss or vasovagal response 3

• Persistent bleeding beyond 1-2 weeks should be evaluated, as normal post-procedure bleeding typically decreases gradually 3

Special Follow-Up Considerations

• After molar pregnancy evacuation, check hCG every 1-2 weeks until normalized; rising or plateauing levels indicate persistent gestational trophoblastic neoplasia 3

• Persistent or recurrent abnormal bleeding despite benign pathology warrants repeat evaluation with hysteroscopy, as the 10% false-negative rate of D&C cannot be ignored 1, 2

• When D&C shows grade 1 endometrioid cancer in a young woman desiring fertility, hysteroscopy should be repeated to confirm the grade before initiating conservative management 1

Common Pitfalls and How to Avoid Them

Diagnostic Errors

• Never accept a negative office biopsy as reassuring in a symptomatic postmenopausal woman—the 10% false-negative rate mandates escalation to D&C or hysteroscopy 1, 2

• Blind D&C frequently misses focal lesions (polyps, submucous fibroids, localized hyperplasia); always consider hysteroscopy when available 1, 4

• D&C performed in women with endometrium <7 mm has similar diagnostic yield to office sampling; in women with endometrium ≥7 mm, D&C is superior to office devices 6

• Microcurettage devices (Gynoscann, Endorette) cannot replace D&C in women ≥50 years without risk of missing significant pathology, including all four endometrial cancers in women <50 years in one study 7

Procedural Complications

• Uterine perforation risk is four times higher when performed by operators with <500 procedures; ensure adequate training and supervision 1

• Infection risk increases with retained products of conception and prolonged procedure time; use systematic curettage technique and consider prophylactic antibiotics in high-risk patients 3

Management Errors

• Never proceed directly to hysterectomy without tissue diagnosis—this exposes patients to unnecessary surgical risk if pathology is benign 2

• Do not stop tamoxifen empirically for bleeding—establish whether endometrial cancer is present before modifying treatment 2

• In Lynch syndrome carriers, continue annual endometrial biopsy surveillance starting at age 30-35 years regardless of current findings, given their 30-60% lifetime risk 2