|
By Mindy Bilgrey, HealthAtoZ contributing writer
One of the most common surgical procedures performed in this country may be both inappropriate and ineffective for many women.
On average, 220,000 women each year undergo dilation and curettage, often referred to as the "D&C", a procedure that entails scraping the uterine lining. The D&C is often recommended to treat menorrhagia, or excessive menstrual bleeding (EMB), a condition that can be very debilitating and severely impact the quality of life of many women.
According to the American College of Obstetricians and Gynecologists, a normal menstrual cycle occurs about every 28 days, with a menstrual period lasting as long as seven days. Abnormal uterine bleeding occurs when a woman continues to bleed beyond seven days, her period is heavier than normal, or she experiences bleeding between her periods.
The American Academy of Family Physicians reports a number of causes of abnormal uterine bleeding, some of which can contribute to EMB:
- Hormonal imbalance (increased estrogen levels or decreased progesterone levels)
- Uterine polyps
- Fibroid tumors
- Uterine cancer
- Cervical infection
- Thyroid problems
What is a D&C?
The D&C is usually performed in a hospital with the woman receiving either general or local anesthesia. An instrument called a speculum is inserted into the vaginal canal. Once the speculum is opened, the physician has a clear view of the cervix. Then the cervical canal is dilated by inserting a small metal rod. Next, a curette, a surgical instrument that has a handle with a metal loop on the end of it, is inserted into the uterine cavity through the opening in the cervical canal. Using the curette, the physician scrapes the endometrial lining on the inside of the uterus and a sample is usually collected to biopsy.
"As a diagnostic procedure, the D&C does not give us the most accurate picture of the cause of heavy bleeding," says Roger P. Smith, M.D., professor, vice chairman and program director of the department of obstetrics and gynecology at the University of Missouri in Kansas City, Kan.
New treatment
Smith, along with other researchers, authored a new teaching monograph, released by the Association of Professors of Gynecology and Obstetrics (APGO), "Clinical Management of Abnormal Uterine Bleeding." The monograph asserts that newer surgical techniques provide better options for treating women with EMB than the D&C. Newer surgical procedures include hysteroscopy with endometrial biopsy, which uses a tiny lighted tube to look inside the endometrial cavity, and endometrial ablation, which removes the uterine lining through the use of heat, freezing or other methods. It should be noted that after an endometrial ablation, a woman can no longer bear children.
Smith adds that D&C treatment often only provides temporary relief from heavy bleeding, and the procedure sometimes needs to be repeatedly performed in order to control the condition. He says women should explore the newer options available that can provide longer-term satisfaction.
"In the past the D&C was thought to be both diagnostic and therapeutic, and that's no longer entirely true," says Linda Bradley, M.D., director of hysteroscopic services in the department of obstetrics and gynecology at The Cleveland Clinic Foundation in Ohio and coauthor of the APGO monograph.
According to Bradley, if a woman is experiencing EMB, her diagnostic and treatment process should include a stepwise approach:
- A physician office evaluation with either hysteroscopy or saline infusion sonography
- Medical therapy if appropriate
- If polyps or fibroids are found, then treatment with an operative hysteroscopy
"The D&C is like trying to paint a room while wearing blinders - after you take the blinders off, you see the areas you missed. The D&C is a non-guided test, where the doctor scrapes the tissue - but can't scrape the entire endometrium," Bradley says.
Diseased tissue can be left, she says, because the physician doesn't know it's still there. By using the hysteroscope the doctor can see exactly what the pathology is and can be assured that an entire lesion has been removed.
Bradley makes the point that gynecologists are now catching up with other specialists when it comes to the area of diagnostic testing. For example, she says, if a patient has bleeding from the bladder, a physician would use a cystoscope; for bleeding from the rectum, the instrument would be a colonoscope; if someone were vomiting blood, an endoscope would be used and if a surgeon were repairing a patient's knee, he or she would use an arthroscope. Using the hysteroscope enables the physician to be far more accurate, with a panoramic view of the endometrial cavity.
"The D&C as a technique should no longer be applicable in modern gynecology," Bradley says. She advises if a woman has been told by her physician that she needs a D&C, she should get a second opinion with a physician who understands the new stepwise approach.
This article was reviewed and updated June 2007.
Return to the previous page
|
