Dilation and Curettage

Whatis Dilation and Curettage?

Dilationand curettage - sometimes referred to by your gynecologist as a "D&C" is a gynecological procedure normally performed through the vagina, wherein thedoctor dilates the cervix and inserts a curette through the vagina, and the nowdilated cervix, and into the uterus, for cleaning out or scraping the lining of theuterus. This gynecological procedure is normally done while the woman is undergeneral anesthesia.

D&Cs areperformed to resolve abnormal menstrual or uterine bleeding wherein a woman'sbleeding may be too much, too often or her menstrual flow may be too heavy.

Whatare Menstrual Disorders?

Menstrual disorders can be either a temporary or permanent condition.  Bothmenstrual disorders can interfere with a woman's ability to become pregnant. 

A woman with menstrual disorders needs to see her ob/gyn or family doctor asmenstrual disorders may be signs or symptoms of  more serious medicalconditions. 

Menstrualdisorders can result from conditions that affect a woman's hormone-producingglands and organs that may include her cervix, hypothalamus, ovaries, pituitary gland, uterus,or vagina.

Themost common menstrual disorders are:

Amenorrhea- which is the absence of of a woman's menstrual periods.

Dysmenorrhea- also known as painful periods with severe menstrual cramping.

Menorrhagia- excessive menstrual bleeding.

Oligomenorrhea - which is infrequent (less than 8 periods/menstrualcycles per year) menstruation.

Amenorrheais the absence of menstruation or a woman's monthly menstrual periods. Amenorrheais classified as either "primary" Amenorrhea,which is the absence of "menarche" a girl's first menstrual period by age16, or "secondary" Amenorrhea,which is the absence of menstrual periods for more than three to six months in a woman who previously hadmonthly menstrual periods.

Causes of primary amenorrheawhich are normally present at the birth of a baby girl, but are not known untilshe reaches the age of puberty, and when she should be experiencingmenarche.  Conditions causing primary amenorrhea may include genetic or chromosomal abnormalities, and structural abnormalities of the reproductive tract. All of the conditions that lead to secondary amenorrhea can also cause primary amenorrhea.Pregnancy is the leading cause of secondary amenorrhea. 

Amongnon-pregnant women, ovarian conditions are the most common cause of secondary amenorrhea; these conditions include polycystic ovary syndrome andpremature ovarian failure also known as early premature menopause.

Themost common reasons for Amenorrhea,skipped menstrual periods or missingmenstrual periods include:

*  Emotional stress
*  Excessive exercise or physical stress
*  Poor nutrition
*  Pregnancy
*  Illness

Dysmenorrhea or painful periods is the medical term for severe menstrualcramping. "Primary dysmenorrhea" is not usually associated with othermore serious medical conditions. Dysmenorrhea  usually begins when a girlstarts having her menstrual periods, and can start as soon as her first periodor menarche. 

Menorrhagia- or excessive menstrual bleeding, is normally indicated when a woman's menstruationlasts more than seven to eight days each monthly menstrual period, or if sheloses more than 80 milliliters or about 1/3 of a cup of menstrual blood eachmonthly cycle. A woman's doctor may classify or diagnose her as having dysfunctionaluterine bleeding (DUB), which often leads to an iron deficiency or anemiaunless she begins taking iron supplements, as prescribed by her doctor. Iron deficiency, as caused by the excessive menstrual bleeding, may lead to increasedfatigue, dizziness, shortness of breath, and in severe cases - angina.

Menorrhagia'smost likely causes include:

* Abortion-related problems
*  Cervical or endometrial polyps
*  Cervical cancer
*  Endometrialcancer.
*  Hormoneimbalance
*  Intrauterine Devices (IUDs)
*  Menopause
*  Pelvic inflammatory disease (PID)
*  Perimenopause
*  Premature Ovarian Failure
*  Uterine fibroids or tumors (benign or cancerous)

Oligomenorrhea is another menstrual disorder that refers to infrequent orsporadic menstrual periods which are generally defined to mean fewer than six to eight periods peryear.

Alternativesto Hysterectomy: 
New Technologies, More Options

Morethan 1 in 4 U.S. women will have a hysterectomy by the time they are 60 yearsold, according to the Centers for Disease Control and Prevention (CDC).

Ahysterectomy--removal of the uterus--can be a life-saving operation for womenwith certain types of cancer or uterine hemorrhage. It can also improve thequality of life for thousands of women each year who experience abnormal uterinebleeding and noncancerous growths of muscle tissue in and around the uterus(fibroids), or the falling of the uterus from its normal position into oroutside of the vagina (uterine prolapse).

Whenthe ovaries are also removed, a hysterectomy can relieve the pain ofendometriosis--the growth of the tissue lining the uterus (endometrial tissue)outside the uterus.

TheUnited States has one of the highest rates of hysterectomy in the world, withabout 5 out of every 1,000 women each year having the operation, according tothe CDC. Other industrialized countries show lower rates; in England, forexample, the rate is less than 3 per 1,000 women annually. In Norway, it's lessthan 2 in 1,000.

Someare concerned that many hysterectomies are done unnecessarily in this country."There are some cases where hysterectomy is the only option, for instance,for some types of cancer," says Anthony Scialli, M.D., director of theobstetrics and gynecology residency program at Georgetown University Hospital inWashington, D.C. "But I think we perform too many hysterectomies. It's amatter of American gynecologists being accustomed to performing a hysterectomyand American women being accustomed to getting one--based on their mother orother female relative having one. The one thing in favor of a hysterectomy isthat it works for abnormal uterine bleeding--but it should be the last step, notthe first step."

Ofthe more than 600,000 hysterectomies performed on American women in 1999, morethan one-third of them were to treat fibroids or abnormal uterine bleeding.

Today,women have other options--new medications, technologies, and procedures--totreat noncancerous uterine conditions. Some of these less invasive procedurestranslate into lower risk, quicker recovery, and less expense. And some preservethe ability to get pregnant, unlike hysterectomy.

However,these procedures also have the disadvantage inherent with any new treatment--thelack of data demonstrating long-term safety and effectiveness. "But it'snever a bad thing for a woman to ask a doctor for alternatives," saysScialli. "She should ask, 'What other options are there to manage thisproblem and what are the pros and cons?'"

AbnormalUterine Bleeding

Inwomen younger than 30, most hysterectomies are done to treat abnormal uterinebleeding. Abnormal uterine bleeding can occur as frequent, irregular andunpredictable bleeding, lengthy menstrual periods, bleeding between periods, ora heavy flow during periods. This bleeding may be caused by hormonal imbalances,growth of endometrial tissue into the wrong place, fibroids, or otherconditions. And sometimes the bleeding has no identifiable abnormalityassociated with it.

Howeverit occurs, abnormal uterine bleeding is an inconvenience, and it can beaccompanied by painful cramping. It can also be exhausting, embarrassingand--when it results in anemia--dangerous.

Afterdiagnosing the cause of bleeding, doctors usually turn to medications as thefirst therapy for treating abnormal uterine bleeding. Some estrogens andprogestins are approved by the Food and Drug Administration to treat abnormaluterine bleeding in certain circumstances. Although the FDA has not approvedoral contraceptives to treat abnormal uterine bleeding, some doctors prescribethem for this purpose. As with other approved medications, doctors may prescribeoral contraceptives "off label" for an unapproved use if, in theirprofessional judgment, a patient will benefit from them.

"Ninety-fivepercent of abnormal bleeding associated with or without fibroids can becontrolled with birth control pills," says Scialli. However, oralcontraceptives may not be effective in reducing bleeding to acceptable levels insome women.

EndometrialAblation

Forsome who experience abnormal uterine bleeding, a viable alternative tohysterectomy can be endometrial ablation. This procedure--a minimally invasivesurgery that uses electrical energy, heat, or cold to destroy the endometrium--mayminimize or even stop this bleeding. But the results may not be permanent."Within 10 years, most women will have some degree of menstrual bleedingreturn, but not heavy bleeding," says Scialli.

Theearly techniques of endometrial ablation, introduced in the 1980s and stillpracticed by many gynecologists, are also known as "operativehysteroscopy" because they use a hysteroscope (a thin, fiber-optic tube forviewing) with an attachment to destroy tissue. The attachment may be a "rollerball"or wire loop through which electrical heat travels to remove (resection) theendometrial lining. After the uterus is filled with fluid to enlarge it forbetter viewing, the surgeon moves the rollerball back and forth across thelining or uses the wire loop to shave off the tissue. Potential risks of thisablation method include infection, perforation of the uterus, cervicallaceration, and absorption of large volumes of fluid (fluid overload) that canlead to death.

In1997, the FDA approved ThermaChoice, the first non-hysteroscopic ablation deviceto treat excessive uterine bleeding (menorrhagia) due to benign (noncancerous)causes. In 2001, the FDA approved three more similar devices. These devices areto be used only in women who have not yet reached menopause and whosechildbearing is completed.

"Eachtype of ablation represents a simpler surgical procedure for doctors compared totraditional operative hysteroscopy," says Colin Pollard, a biomedicalengineer and chief of the ob/gyn devices branch in the FDA's Center for Devicesand Radiological Health. "All of the technologies have some things incommon, but each delivers energy differently and each offers different feedbackmechanisms to the doctor during the procedure."

TheThermaChoice Uterine Balloon Therapy System, manufactured by Gynecare, adivision of Ethicon Inc. of Somerville, N.J., consists of a balloon that isinserted through the neck of the womb (cervix) and into the uterus. Through acatheter connected to a controller console, the balloon is inflated with fluidand heated to 188 F (87 C) for eight minutes to destroy the uterine lining.

Thefirst of the three newer devices--the Hydro ThermAblator manufactured by BEIMedical Systems Inc. of Teterboro, N.J.--delivers hot salt water (salinesolution) into the uterus through a tube inserted into the cervix. The hot waterdestroys the uterine lining in about 10 minutes. The doctor uses a hysteroscopefor viewing the uterus during the procedure.

Thesecond device--Her Option Uterine Cryoblation Therapy System made by CryoGenInc. of San Diego--uses a probe capable of producing temperatures down to minus148 F (minus 100 C) at the tip. This extreme cold is applied to the tissue for10 minutes to freeze and destroy the uterine lining. Ultrasound is used to guideand monitor the procedure.

Thethird device--the NovaSure Impedance Controlled Endometrial Ablation Systemmanufactured by Novacept of Palo Alto, Calif.--uses a metallic mesh triangularelectrode that is expanded out of a slender tube into the uterus. A gentlesuction brings the tissue into close contact with the triangular electrode,which delivers electrical current to the endometrial tissue, causing itsdestruction in about 90 seconds. With this method, there is no hysteroscope orultrasound, so the doctor cannot view the uterus during the procedure.

NotFor Everyone

Endometrialablation is not advised for women who want to have children, and it is not aform of birth control. "Doctors must tell the patient she should stillmaintain contraception," says Pollard. "If she does get pregnant, itwill be a very high-risk pregnancy." If pregnancy were to occur, the cellsleft lining the uterus may not be adequate for a fetus to attach and grow withinthe uterus.

TheThermaChoice balloon method has the longest track record of the newer, simplerablation techniques. A three-year study of this device and one-year studies ofthe ablation devices approved this year--the Hydro ThermAblator, Her Option, andNovaSure--showed similar rates of effectiveness and were comparable to theeffectiveness of operative hysteroscopy (such as the rollerball technique). Theyall reduced or stopped bleeding in 70 percent to 80 percent of the women tested.

Unlikea hysterectomy, the newer endometrial ablation procedures can be performed withlocal anesthesia. Ablation is usually done in the hospital on an outpatientbasis; however, some women remain overnight to treat the severe abdominal painthey may experience. Most women are able to return to their regular activitiesseveral days later.

Commonside effects after the procedure include nausea, vomiting, and a vaginaldischarge that can last from days to weeks. "Expect to have bleeding up tofour to six weeks," says Malcolm Munro, M.D., a professor and gynecologistat UCLA. "With ablation, you are traumatizing the surface whether you useelectrosurgery, or burn it or freeze it."

Complicationsof ablation are rare, but may include blood loss requiring a transfusion,perforation of the uterus, or unintended damage to other internal organs.

Newerapproaches to endometrial ablation are currently under investigation; these useother energy sources, such as laser and microwave, to destroy the endometrialtissue.

APersonal Choice

Awoman must decide what she expects from a treatment for abnormal uterinebleeding. "Women need to know that articulating their problem is importantfor treatment," says Munro. "With abnormal bleeding, the desiredoutcomes vary. Some women want no period, some want a predictable period. Somewant to slow the bleeding, for others pain is more important than volume. Somewant to maintain their ability to get pregnant. Some don't want scars; somedon't care about scars. Time off is a consideration. All of these factors areimpossible for a doctor to aggregate for the patient. The woman has to make thedecision."

Manywomen are satisfied with the outcomes of their endometrial ablations. Butothers, like Melissa Otto of Minneapolis, are disappointed.

Otto'shormonal introduction to womanhood--when she was 12--was frightening. Shortlyafter the onset of menstruation, her monthly period became very heavy andlengthy. By the time she was 14, Otto was extremely anemic from the blood loss."The doctors told my parents not to worry--that eventually I'd regulate andhave a normal period. They said 'Let's just treat the anemia for now.'"

ButOtto's bleeding was no more regular by the time she reached her 20s. Medicaltests ruled out fibroids and other abnormalities. Despite trying many differenttypes of birth control pills prescribed by her doctor, her periods continued toget heavier. They came about every 23 days and lasted for 12 to 13 days. Ottospotted during the 10 days a month she wasn't bleeding heavily.

Indesperation, Otto tried hormone injections, homeopathic remedies, chiropracticmedicine, blood-building supplements, and acupuncture. Nothing worked.

InMay 1999 when she was 31, Otto had an endometrial ablation. Her doctor used alaser to destroy the endometrial tissue. After five weeks of watery dischargeand spotting, Otto's periods resumed and became frequent and lengthy once more.

InJuly 2000, Otto checked into the hospital for a second endometrialablation--this time a balloon ablation. Four weeks later, her period returned--alittle lighter--but still long.

After20 years of problem periods, a dozen different doctors, hormone treatments, twoablations, and a bout of cervical cancer along the way, Otto had had enough. InMarch 2001, she had a hysterectomy, and Otto says that she is very happy withthe results.

Fibroids

Uterinefibroids may be a cause of abnormal uterine bleeding. About 30 percent of womenbetween 25 to 45 are diagnosed with fibroids, according to the federal Agencyfor Healthcare Research and Quality.

Forunknown reasons, fibroids are diagnosed in black women two to three times morefrequently than in white women, and fibroids account for about twice the numberof hysterectomies among black women than among white women, according to theCDC. About 200,000 hysterectomies each year are performed in the United Statesto treat fibroids.

Alsocalled myomata or leiomyomata, fibroids can vary from microscopic size to thesize of a melon, and no one knows what causes them.

Mostfibroids do not cause symptoms and require no treatment other than regularmonitoring by a physician. But some fibroids can cause heavy bleeding,debilitating pain, or both. If fibroids press on the bladder or bowel, they cancause frequent urination, constipation, painful bowel movements, andhemorrhoids.

Largefibroids may cause an enlarged uterus, resulting in a protruding abdomen."When the uterus reaches the size of a melon, a doctor would most likelyrecommend a hysterectomy," says Dena Hixon, M.D., a gynecologist in theFDA's Center for Drug Evaluation and Research. No treatment other thanhysterectomy can guarantee that uterine bleeding or fibroids won't recur.

TreatmentOptions

Thereare medications that will temporarily shrink fibroids. If heavy bleedingaccompanies the fibroids and causes anemia, a doctor may prescribe an injectionthat temporarily stops estrogen production for up to three months beforesurgery. Most fibroids are stimulated to grow by estrogen, and without it,fibroids usually shrink. These injections, called gonadotropin-releasing hormone(GnRH) agonists, act by causing a sort of medical menopause, says Hixon."These are drugs with significant risks and side effects that are mostappropriately used when other common alternatives are inadequate or notappropriate for the individual." Because of their significant side effects,including loss of bone density, hot flashes, and mood swings, the FDA hasapproved GnRH agonists for use only for three months. Without surgery, thefibroids are likely to regrow after the drug is stopped.

Womenwith fibroids that cause pain, discomfort or bleeding have surgical options tohysterectomy. These include surgically removing only the fibroids (myomectomy),cutting off the blood supply to the fibroids (embolization), and shrinking thefibroids using electric current (myolysis). Myolysis is not currently widelyused, and no long-term studies on safety and effectiveness have been done onthis procedure. The most appropriate treatment for each woman will depend on thesize and location of the fibroids, the severity of symptoms, and futurechildbearing plans.

Beforetreating fibroids, a gynecologist should perform a pelvic exam and sonogram,says Thomas Lyons, M.D., a gynecologist at the Center for Women's Care andReproductive Surgery in Atlanta. If abnormal bleeding occurs a physician shouldalso take a sample of the uterine lining to check for cancerous cells or otherproblems that may warrant a different treatment.

Samplingcan be done by dilation and curettage (D&C) or by endometrial biopsy.D&C is a procedure that involves dilating the cervix and scraping theuterine lining. In an endometrial biopsy, a thin hollow tube is inserted throughthe cervix and into the uterus. Cells in the uterine lining are pulled throughthe tube by suction and later tested in a lab.

Uterinesarcoma, a rare cancer, cannot be diagnosed by testing samples of endometrialcells. Nevertheless, sampling is recommended to check for other cancers ordisease before treating fibroids or abnormal uterine bleeding.

Myomectomy

Amyomectomy is a surgery to cut away the fibroids without removing the uterus, sothat a woman can maintain her ability to bear children. "It's major surgeryand has the same disadvantages as hysterectomy as far as pain, disability, andscarring are concerned," says Scialli. "But if a woman wants to getpregnant, myomectomy is currently the method with the best track record." Amyomectomy tends to weaken the uterine wall; children born after the proceduremay need to be delivered by cesarean section.

Insome cases, a myomectomy may be a more complicated procedure than ahysterectomy. "After you remove the fibroids, you have to reconstruct theuterus," says Lyons.

Myomectomycan be performed in several different ways, depending on the size and locationof the fibroids. In a laparotomy, a surgeon can go into the uterus through anincision in the abdomen. In another approach, a laparoscopy, the surgeon insertsa telescope-like instrument (laparoscope) through the navel and inserts otherinstruments through very small incisions in the abdomen. Scialli does notgenerally recommend a laparoscopic myomectomy for women having a subsequentpregnancy because it may weaken the uterine wall more than a myomectomy donethrough a larger abdominal incision.

Anothermethod of myomectomy involves using a hysteroscope and small surgicalinstruments inserted into the uterus through the cervix to cut out the fibroids.Sometimes, the surgeon uses a special type of hysteroscope called a resectoscope.This instrument has a built-in wire loop and uses electrical current to cut outthe fibroid. Even after a myomectomy, fibroids can still be a problem, saysScialli. "I've seen patients who never have fibroids return and patientswhose fibroids recur every bit as badly within a year."

UterineFibroid Embolization

Uterinefibroid embolization (UFE)--also called uterine artery embolization (UAE)--is aminimally invasive procedure that blocks the arteries carrying blood to thefibroids. Because the procedure is performed by a specially trained physiciancalled an interventional radiologist, a woman should first be examined by agynecologist, says Lyons. The gynecologist will take the patient's medicalhistory and perform tests to rule out any problems that may be causing thebleeding and that would require a different treatment.

Inthe procedure, which is done under local anesthesia, the radiologist threads asmall tube (catheter) from the groin into the uterine artery. The radiologistthen injects a dye into the artery and views moving X-ray images on a monitor tosee the flow of blood to the fibroids. Very small particles, called embolicagents, are slowly injected through the catheter to the uterine artery in orderto block the blood supply to the fibroids. (See"Uterine Fibroid Embolization.") A clot forms around theparticles, which are about the size of grains of sand and are usually made fromplastic (polyvinyl alcohol) or gelatin sponge.

"Uterineartery embolization is a procedure that doctors have been doing as long as 20years, but not specifically for uterine fibroids," says the FDA's Pollard."The procedure has been used for postpartum hemorrhaging and to stopbleeding when treating some kinds of cancer."

Sincethe mid-1990s, the use of uterine artery embolization to treat fibroids hasgrown. According to the Society of Cardiovascular and Interventional Radiology,more than 10,000 procedures have been done worldwide, of which about 8,600 wereperformed in the United States. Three deaths have been reported.

Althoughthe FDA has not cleared the UFE procedure for general use, it is being studiedin FDA-approved clinical trials. "It is not a trivial procedure and is notwithout risks," says Pollard. "And we're not sure how those risksweigh up against drug therapy, myomectomy, and hysterectomy." Potentialrisks include infection, ovarian failure leading to early menopause, andexpulsion of the fibroid from the uterus at a later date, requiring anotherprocedure. Additional risks include leakage of the embolic particles out of theblood vessels, complications from radiation exposure, blood clotting in theveins of the inner thigh or leg (deep vein thrombosis), blockage of an artery inthe lungs (pulmonary embolus), and death.

Unlikea hysterectomy, UFE leaves the uterus intact, with the potential forchildbearing. However, current research is lacking on the ability to becomepregnant and carry a baby to full-term, says Pollard.

MoreData Needed

Comparedto hysterectomy, minimally invasive surgeries to treat uterine problems arerelatively unknown territory. "While these are promising technologies, wedon't have data on their long-term safety, effectiveness, and fertility,"says Amy Allina, program director of the National Women's Health Network, anonprofit women's health advocacy organization in Washington, D.C. "It's amatter of choice. I don't consider any of these options perfect foreverybody."

Nevertheless,women today do have a multitude of good options to choose from to maintain theirhealth, says Lyons. "Information about these options is out there butindividuals must access this knowledge in order to take advantage of thesechoices. Be proactive and know all you can know to best serve yourself and yourfamilies."

ForMore Information

NationalWomen's Health Network
514 10th St., N.W., Suite 400
Washington, DC 20004
202-628-7814
www.womenshealthnetwork.org

NationalWomen's Health Information Center
1-800-994-WOMAN (1-800-994-9662)
TDD: 1-888-220-5446
www.4woman.gov

NationalUterine Fibroids Foundation
1-877-553-NUFF (1-877-553-6833)
www.nuff.org

EndometriosisAssociation
1-800-992-3636
www.endometriosisassn.org