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Curettage and hysteroscopy CURETTAGE AND HYSTEROSCOPY
When it comes to disorders affecting the uterus, the procedure known as dilatation and curettage (D and C) is grossly overused. There is now ample research indicating it has significant shortcomings, yet it continues to be carried out both to provide samples of tissue for further investigation and as a 'treatment' for women with menstrual irregularities. In fact, its ability to provide useful samples for diagnostic purposes is quite limited; and when used for treatment purposes it is very disappointing, reducing menstrual flow for only one cycle in most women. In 1991-92 in New South Wales alone, more than 35 000 D and Cs were performed, suggesting that the annual figure for this procedure in Australia probably exceeds 100000.
The D and C technique is usually carried out under a general anaesthetic in a day hospital or general hospital setting. During dilatation, the cervix is gently stretched open by inserting progressively larger instruments. This is followed by a curette in which the endometrium is gently scraped away using an elongated instrument with a scoop attachment.
An alternative diagnostic procedure that can be used when a detailed patient history, examination and laboratory tests have failed to reveal the cause of abnormal bleeding is hysteroscopy. A hysteroscope is basically a tubular instrument with a light at one end and an optical system for transmitting an image to a display monitor. It is inserted through the vagina and cervix to observe the inside of the uterus. After obtaining ultrasound images of the uterus and introducing gas to separate the pelvic organs, the cervical canal is gently stretched to allow the hysteroscope to pass into it. It is then possible to get a good view of the uterus in about 80% of patients. (In the remaining patients, the view may be obscured by heavy bleeding.) Of women with menstrual irregularities in whom the uterus can be observed, more than 60% have no apparent uterine abnormality. These women are spared a diagnostic curettage. The others may have fibroids, polyps, endometriosis, pre-cancerous changes or endometrial cancer. If any area of abnormality is identified, a sample can be removed, checked by a pathologist and, in many cases, destroyed on the spot by an instrument inserted through the hysteroscope.
Hysteroscopy is thus a useful diagnostic test which can be used as the basis for treatment. It can be carried out without hospital admission or general anaesthesia, a considerable benefit in the eyes of many women (particularly those who are elderly and have multiple medical problems). A study by the University of Adelaide and the Royal Adelaide Hospital suggests that Australia's health budget could be reduced by at least $30 million a year if outpatient hysteroscopy (also called office hysteroscopy) was adopted instead of performing D and C procedures in day surgery units.9 This 1994 study quoted the cost of a hysteroscopy at about $100, while a D and C cost over $500 when carried out in a day surgery unit and over $1000 if an operating theatre and overnight stay were required.
Serious complications such as bowel perforation occur in less than 1% of patients having a hysteroscopy, but about 70% experience the discomfort of menstrual-type pain, sensations of dizziness, tremor, shoulder tip pain or nausea, which is often followed by vomiting. If doctors explain possible side-effects before the procedure starts, this can help to reduce anxiety in patients when they occur. As increasing numbers of gynaecologists become familiar with the technique of hysteroscopy, it is hoped that D and C will be used more selectively.
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