D and C

What do the initials D & C stand for?

They stand for dilatation and curettage – which exactly describes what the operation does. It involves widening the neck of the womb slightly (dilating it) so that the doctor can scrape away the spongy surface layer of the womb lining.

The operation requires a general anaesthetic, but it leaves no scars and has no side effects. At most it means you’ll have to spend a day in hospital.

Removing some of the wombs lining doesn’t do any harm at all. The lining is temporary anyway, building up each month under the influence of the body’s natural hormones for three to four weeks before each period. When a woman has a period, she sheds this lining-and then the whole process starts again.

The opening of the womb- cervix –is really a ring of muscles designed to stop a baby fro slipping down from the womb into the vagina before its time. Until then, the opening is tiny-its looks like a little more than a dimple but it’s just enough to to allow fluids to pass in and out, so that sperm can reach an egg, or the womb lining can be shed each month. After you have had a baby, although the cervix contracts again, the opening is a little wider than before.

But for doctor to be able to scrape the womb lining, the cervix has to be stretched gently with small instruments known as dilators until the muscles relax enough to admit the small scraper or curette. After the operation, the muscles tighten up again of their own accord.

How is a D & C carried out?

You won’t feel a thing when you have a D & C because the operation is done under general anaesthetic. Once this has taken effect, the surgeon will gently open the vagina with aid of an instrument called a speculum, which makes it easier for him to see and reach the cervix. His next priority will be to find out the angle of the cervical canal and to establish the size of the womb itself, so that he knows how far to insert the curette. To do this he uses the a smooth metal probe called uterine sound which he pushes gently along the canal into the womb until he has made contact with the far side, about five centimeters from the opening.

Once he has the measure of it, the doctor can begin to dilate the cervix gently. Several dilators are used, each one fractionally larger in diameter than the one before, varying in thickness from the size of a matchstick to that of a small finger. Each has a smooth blunt head. The doctor passes the dilators, one at a time, through the cervical canal and back again, starting with the smallest and using each one in turn. Gradually, the ring of muscle begins to loosen up, just as any muscle naturally does with use, until the opening is wide enough to pass the curette through.

The doctor can now scrape the womb lining away with curette (which looks like a long, thin spoon at the end of which is tiny scraper that works rather like a potato peeler) He rotates the instrument so that he can reach and remove the top layer from every part.

Are there any side effects?

When the anaesthic wears off there may be some discomfort- a little bleeding and a feeling of pain in the lower stomach similar to a period pain. Some women say this feels ‘as if I had been punched’. The bleeding is only the result of the womb shedding a little extra blood in response to the scrape, and is nothing to worry about.

The pain usually lasts only a few hours and can be helped by analgesics (pain killers) and, much like an ordinary period, the bleeding only goes on for a few days. The next period should arrive within the following four or six weeks, but may be a little lighter than usual.<

Since there have been no cuts made and so no stitches, there will be no scars.

Having a D & C is nothing to worry about and shouldn’t cause any disruption to life at all. Only bear in mind that you shouldn’t have sexual intercourse for a few days afterwards until bleeding has stopped and, during this time, use pads rather than tampons.

When will a doctor recommend a D & C?

Whenever a woman has abnormally heavy, prolonged or irregular periods, or if she has started bleeding (even slightly) between periods, a doctor may recommend a D & C.

The causes may vary but taking a sample from the lining of the womb, and testing it in the laboratory, doctors can find out whether there have been any changes in the cells of the womb themselves and whether the problems are likely to have a hormonal basis.

Sometimes the problem may be very obvious- it may be that a polyp or fibroid has developed. These benign (harmless) growths are very common, provoking heavy, prolonged periods or even causing bleeding midway through a cycle. If a doctor finds either of these growths during a D & C he may remove them straight away.

But many women have irregular or heavy periods from time to time and a doctor may not always recommend a D & C. Age certainly comes into it. A doctor will not recommend a ‘scrape’ for a 19year old who complains of heavy, painful periods, but certainly will for a 55year old woman who has begun bleeding slightly some years after her periods have stopped.

Can a D & C help in treating painful periods?

Yes, in certain cases, but only the dilation part of the operation is used, and it’s only effective in stopping the pains in about one in third of the women who have the operation. Although it is not known exactly why a D & C works foe painful periods it seems likely that stretching the muscles of the cervix allows menstrual blood to flow more freely. Doctors usually prefer, though, not to stretch the neck of the womb in woman under the 20, rather waiting to see whether the problem clears up of its own accord. Many alternative forma of treatment are now available.

Periods Re generally most painful for younger women but get progressively less so once woman begin to have regular sex. Certainly after a woman has a baby, she usually finds the problem eased. In fact, nowadays painkillers or hormone tablets like the pill are often used in preference to a D & C to treat period pains. The results of this treatment are usually very good.

Is it true that the operation is used too detect cancer?

Unexpected or heavy bleeding from vagina can be a sign of cancer of the womb- or any one of the other disorders already mentioned. But because older women (between 45 and 60) are more at risk, a doctor will almost invariably recommend they have a D & C in order to establish the cause. Of course this is bound to be worrying, but the chances are that the symptoms have a much simpler explanation. After menopause, some women do have ‘flooding’ periods which suddenly occur out of the blue as a result of some hormonal imbalance, which can easily be treated.

Once a scrape has been performed, the tissues can quickly be analysed in a laboratory and the doctor can then start appropriate treatment. Fortunately, even if the results do indicate a cancer, this is a type which responds well to treatment and the chances of a complete cure are high, particularly if it’s caught in the early stages. For this reason it’s obviously sensible to consult your doctor, whatever your age, if you do experience any of these symptoms.

Is the operation sometimes used as a method of abortion?

Before the tenth week of pregnancy a D & C can be used to terminate pregnancy. However, it is far less common than the D & C operation (dilation and evacuation) which involves the use of suction rather than a scrapping action.

The reason is that in early pregnancy the womb lining is richer and softer than normal and a surgeon has to take special care not to damage the soft and thickened muscle wall of the womb which could tear and bleed easily.

Sometimes a pregnancy fails during the early weeks but instead of miscarrying, the foetus, though no longer living, remains inside the womb. This is called a missed abortion and a D & C will usually be required to clear the womb completely.

Similarly a D & C may be necessary just after childbirth if, as sometimes happens, part of the afterbirth placenta is left behind. This may cause heavy bleeding and pain and can lead to infection so a D & C may be necessary to remove the fragments.

What other reasons might there be for recommending a D & C?

There are several other reasons for a D & C-all of them less common than those already mentioned.

It’s often part of a routine series of test for woman suspected of being infertile. By taking a sample of the lining for testing, doctors can tell whether an egg has been released. If a woman isn’t ovulating properly, the body will not have released the oestrogen and progesterone which normally stimulates the development of the womb’s lining: ‘Scrape’ analysis will be able to reveal this.

Of course, this will only be undertaken once the more straightforward reasons for a couple’s infertility-problems with the man’s sperm, for instance-have been ruled out. There are other ways of telling if a woman isn’t ovulating (from blood tests, for example), but a D & C can also give doctors an opportunity to see if there is any obvious deformity or infection of the womb which could be preventing her from conceiving.

Is there a particular time of month when the operation should be done?

Generally a D & C would not be done if a woman is having a period, though this will depend on the urgency of the case.

But sometimes more exact timing is necessary: when checking on ovulation for instance. Then it is important that the D & C is done after the woman would normally have ovulated, about a week before her next period is due.

Does the operation ever lead to complications?

Apart from slight discomfort, there are no side effects, and it is very rare that a complication arises afterwards. On the whole, D & C is the safest operation carried out by gynaecologists. But every operation carries a slight risk and it is possible that the wall of the womb could be perforated by an instrument or that, if a cervix is dilated too quickly or too far the muscles can tear.

This could cause problems during a subsequent pregnancy, since it could mean the neck of the womb opens prematurely, when the weight of the baby presses down on it. The woman may then miscarry. This is called ‘incompetence’ of the neck of the womb. It is a rare condition but can be overcome quite easily once diagnosed.

Occasionally, the operation could lead to an infection, but this is very rare indeed. Usually women feel quite well within a few days of the operation and quickly resume their normal activities. There’s no need to be nervous of having a D&C.

Are there any alternatives to a D & C?

Yes. A small telescope, called a hysteroscope is now being used with increasing frequency. This has the advantage that it can be done without anaesthetic, that the lining of the womb can be viewed and any abnormality detected and sampled directly (directed biopsy).

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