D&C

f all the operations performed for’women’s complaints’ the D C is both the commonest and the most simple. It can be a form of treatment in itself- often for menstrual problems – but it can also be used to diagnose some gynaecological problems by giving doctors a chance to check inside the womb and to take samples of the lining for testing.

Many ‘scrapes’ are taken as a matter of routine for women who are experiencing annoying symp-toms — very heavy periods for instance – and discomfort. Often they show no abnormality at all, or the problem can be cleared up at once as part and parcel of this minor operation.

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 couple of days in hospital.

Removing some of the womb’s lining doesn’t do any harm at all. The lining is temporary anvwav, 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 to the womb – the cervix – is really a ring of muscle designed to stop a baby from slipping down from the womb into the vagina before its time. Until then, the opening is tinv- it looks like little more than a dimple- but it’s just enough 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 a doctor to be able to scrape the worn!) lining, the cervix has to be stretched gently with small instruments known as dilators until the muscles relax enough to admit die small scraper orAfter the operation, the muscles tighten up again of their own accord.

You won’t feel a thing when you have a D & C because the operation is done under a general anaesthetic. Once this has taken effect, the surgeon will gently open the vagina with the 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 a smooth metal probe called a which he pushes gently along the canal into the womb until he has made contact with the far side, two or three inches from the opening.

Once he has the measure or 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 the curette (which looks like a long, thin spoon at the end of which is a 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.

When the anaesthetic 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 the bleeding has stopped and, during this time, use pads rather than tampons.

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 by 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 or 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 the course of 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 is far less likely to recommend a ‘scrape’ for a 19-year-old girl, who complains of heavy, painful periods than for a 55-year-old woman who has begun bleeding slightly some years after her periods have slopped.

Yes, in certain cases, but only the dilatation part of the operation is used, and it’s only effective in stopping the pains in about half the women who have the operation. Although it is not known exactly why a D & C works for painful periods it seems likely that stretching the muscles of the cervix allows the menstrual blood to flow more freely. Doctors usually prefer, though, not to stretch the neck of the womb in women under 20, rather waiting to see whether the problem clears up of its own accord. Above that age, if periods continue to be painful and don’t respond to other treatments, aD&C may be an effective answer.

Periods are generally most painful for younger women but get progessively less discomforting once women 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.

Unexpected or heavy bleeding from the 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 meno-pause, some women do have ‘flooding5 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 taken, 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.

Before the tenth week a D & C can be used to terminate a pregnancy. However, it is far less common than the D & E operation (dilatation and evacuation) which involves the use of suction rather than a scraping 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 take place just after childbirth if, as sometimes happens, part of the afterbirth (placenta) is left behind. This may cause heavy bleeding and bad pain and can lead to infection, so a D & C may be necessary to remove the fragments.

Broadly speaking, the reasons for having this operation fall into two groups:

• for investigating heavy and irregular periods • to establish why there is breakthrough bleeding mid-way between periods • to find the cause of any bleeding after meno-pause • as a routine investigation for infertile women to test for ovulation and check for any deformity • for removing any fibroids or cysts found in the womb • as a treatment for painful periods • to terminate an early pregnancy • to clear the womb after a ‘missed’ abortion • to remove any fragments of placenta left after childbirth 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 tests for women 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; the’ 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 of the womb which could be preventing her from conceiving.

Generally aD&C would not be done while 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 the woman would normally have ovulated, about a week before her next period is due.

Apart from slight discomfort, there are no side effects, and it is very rare that a complication arises afterwards. On the whole, a D &: C is the safest operation carried out by gynaecologists.

But ever)’ operation carries a slight risk and it is possible that the wall of the womb could be perforated by the surgeon’s instrument or that, if the 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.

A woman faced with an unwanted pregnancy is presented with an agonizing choice. Despite the fact that in many countries abortions are now relatively easy to obtain, making the decision to have one is still a very difficult and personal dilemma. It’s a subject that many people have strong emotional views about- sometimes moral and religious beliefs- all of which can bring a lot of pressure to bear on the individual woman. In the end, however, it’s her decision, and the best insurance she can have against feeling depressed about an abortion afterwards is to be sure she is making the choice that feels right for her.