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D & C
What & why!!
What
Just what is a D & C? D & C are initials that stand for "Dilatation & Curettage". On occasion, this has been said to stand for "Dusting & Cleaning" which isn’t really all that bad a description.
According to my Webster’s unabridged, dilatation is "in medicine, enlargement of an organ cavity, duct, or opening of the body, beyond normal size". Curettage is the process of scraping and cleansing with a spoon shaped surgical instrument for removing tissues from the walls of body cavities.
In this case, we are dilating the cervical os or "opening of the uterus". Once the cervix is dilated, we then use the curette (spoon shaped instrument) to scrape the wall of the uterus and remove some of the endometrium or lining of the uterus. Once this tissue is obtained, it can be sent to the pathologist for examination.
Dilatation can be carried out in many ways. If the patient is having a miscarriage, the cervix may already be dilated as a result of the process of miscarriage. More commonly, one uses a set of "dilators". These are usually a set of rods of varying sizes. One starts with a small one and introduces it through the cervix. Then you just keep inserting the next larger size until you have slowly increased the opening to the desired size. Alternatively, one can use a product called "Laminaria Tents" to dilate the cervix. Laminaria are cigarette shaped pieces of a form of sea weed, Laminaria Japonicum, which grows in the Sea of Japan. One or more are inserted into the cervix and left in place for a period of time. They absorb moisture from the surrounding tissue and slowly expand, dilating the cervix.
Once the cervix is dilated, the interior of the uterus can be accessed by a multitude of "curettes" depending on the reason for and the needs of the procedure. If one is performing an abortion or completing a miscarriage, a long plastic tube with a hole on the side near the end is inserted into the cavity. The outer end is attached to suction and the contents of the uterus are aspirated. If one is looking for polyps in the uterus, a pair of grasping forceps is inserted into the uterus and closed. Then they are pulled out of the uterus and if polyps are present, hopefully they will be pulled out in this manner. In the standard D & C, a uterine curette is inserted into the uterine cavity and the wall of the cavity is scraped. The material scraped away from the wall can then be sent for pathological examination.
Why
The reasons for a D & C, have diminished greatly over the last 30 years. When I was a resident D & C was the most common surgical procedure. Now it is a very rare procedure except as related to pregnancy. The most common reasons for D & C today are to perform an abortion or to complete an incomplete spontaneous abortion. (In medical terms a miscarriage is a spontaneous abortion.) Most of these procedures are performed in the office or emergency room using either sedation or local anesthesia.
In most other circumstances, D & C has been replaced by either hysteroscopy or biopsy in the office. Most of the time when we need to look at a piece of endometrium (the lining of the uterus), we insert a tiny flexible plastic catheter through the cervix into the uterus and apply suction to it. This allows us to obtain a small part of the endometrium for microscopic evaluation.
Hysteroscopy is looking inside the uterus through a telescopic like instrument called (believe it or not) a hysteroscope. This is done by first dilating the cervix and then inserting the hysteroscope into the uterus. Through the hysteroscope we can see the lining of the uterus and the openings of the fallopian tubes. If polyps or other growths of the endometrium are seen, a biopsy can be obtained while we are looking at the site we need to biopsy. In other word, it is not just a random sample, but a directed biopsy. Also, utilizing specialized equipment, the endometrium can be destroyed by electrocautery, or fibroids may be surgically resected. There have been many attempts (all unsuccesful so far) to devise a sterilization procedure to be done through the hysteroscope.
R. Daniel Braun, MD
