Dr Vidushi Jyala Jain

MBBS, MS (Obs. & Gynae)
FIART

Obstetrics And Gynaecology

Infertility Specialist

Adhesiolysis

Abdominal and Pelvic Adhesions develop as a result of one or more previous surgical procedures. An adhesion is a band of scar tissue that binds two parts of tissue or organs together.
Not every patient will show signs or symptoms associated with these adhesions, however, it is estimated that 90% of patients undergoing abdominal surgery and 55-100% of patients having pelvic surgery will develop adhesions.

Treatment Options for Adhesions ~ Laparoscopic Adhesiolysis

The removal of adhesions is known as adhesiolysis. Drs. Miklos and Moore are experts in the laparoscopic removal of abdominal and pelvic adhesions. Through their minimally invasive technique and advanced skills, they minimize the likelihood of the recurrence of adhesion formation.

What is a cervical biopsy?

A cervical biopsy is a surgical procedure in which a small amount of tissue is removed from the cervix. The cervix is the lower, narrow end of the uterus located at the end of the vagina.

A cervical biopsy is usually done after an abnormality has been found during a routine pelvic exam or Pap smear. Abnormalities can include the presence of the human papillomavirus (HPV), or cells that are precancerous. Certain types of HPV can put you at risk for developing cervical cancer.

A cervical biopsy can find precancerous cells and cervical cancer. Your doctor or gynecologist may also perform a cervical biopsy to diagnose or treat certain conditions, including genital warts or polyps(noncancerous growths) on the cervix.

Types of cervical biopsies

Three different methods are used to remove tissue from your cervix:

• Punch biopsy: In this method, small pieces of tissue are taken from the cervix with an instrument called “biopsy forceps.” Your cervix might be stained with a dye to make it easier for your doctor to see any abnormalities.

• Cone biopsy: This surgery uses a scalpel or laser to remove large, cone-shaped pieces of tissue from the cervix. You’ll be given a general anesthetic that will put you to sleep.

• Endocervical curettage (ECC): During this procedure, cells are removed from the endocervical canal (the area between the uterus and vagina). This is done with a hand-held instrument called a “curette.” It has a tip shaped like a small scoop or hook.

The type of procedure used will depend on the reason for your biopsy and your medical history.

How to prepare for a cervical biopsy

Schedule your cervical biopsy for the week after your period. This will make it easier for your doctor to get a clean sample. You should also make sure to discuss any medication you take with your doctor.
You may be asked to stop taking medications that could increase your risk of bleeding, such as:

• aspirin

• ibuprofen

• naproxen

• warfarin

Avoid using tampons, douches, or medicated vaginal creams for at least 24 hours before your biopsy. You should also avoid having sexual intercourse during this time.

If you’re undergoing a cone biopsy or another type of cervical biopsy that requires a general anesthetic, you’ll need to stop eating at least eight hours before the procedure.

On the day of your appointment, your doctor might suggest you take acetaminophen (such as Tylenol) or another pain reliever before you come to their office. You may experience some light bleeding after the procedure, so you should pack some feminine pads. It’s also a good idea to bring a family member or friend along so they can to drive you home, especially if you’re given general anesthesia. General anesthesia may make you drowsy after the procedure, so you shouldn’t drive until the effects have worn off.

PROCEDURE

What to expect during a cervical biopsy

The appointment will begin as a normal pelvic exam. You’ll lie down on an exam table with your feet in stirrups. Then your doctor will give you a local anesthetic to numb the area. If you’re undergoing a cone biopsy, you’ll be given a general anesthetic that will put you to sleep.

Your doctor will then insert a speculum (a medical instrument) into the vagina to keep the canal open during the procedure. The cervix is first washed with a solution of vinegar and water. This cleansing process may burn a bit, but it shouldn’t be painful. The cervix may also be swabbed with iodine. This is called Schiller’s test, and it’s used to help your doctor identify any abnormal tissues.

The doctor will remove the abnormal tissues with forceps, a scalpel, or a curette. You might feel a slight pinching sensation if the tissue is removed using forceps.

After the biopsy is finished, your doctor may pack your cervix with absorbent material to reduce the amount of bleeding you experience. Not every biopsy requires this.

Recovering from a cervical biopsy

Punch biopsies are outpatient procedures, which means you can go home right after the surgery. Other procedures may require you to remain in the hospital overnight.

Expect some mild cramping and spotting as you recover from your cervical biopsy. You may experience cramping and bleeding for as long as a week. Depending on the type of biopsy you’ve undergone, certain activities may be restricted. Heavy lifting, sexual intercourse, and the use of tampons and douches are not allowed for several weeks after a cone biopsy. You may have to follow the same restrictions after a punch biopsy and ECC procedure, but for only one week.

Let your doctor know if you:

• feel pain

• develop a fever

• experience heavy bleeding

• have foul-smelling vaginal discharge

These symptoms can be signs of an infection.

Results of a cervical biopsy

Your doctor will contact you about your biopsy results and discuss next steps with you. A negative test means that everything is normal, and further action is usually not required. A positive test means that cancer or precancerous cells have been found and treatment may be needed.

What is endometrial ablation?

Endometrial ablation is the surgical destruction of the lining tissues of the uterus, known as the endometrium. Endometrial ablation is one type of treatment for abnormal uterine bleeding.

Why is endometrial ablation done?

Endometrial ablation is a treatment for abnormal bleeding of the uterus that is due to a benign (non-cancerous) condition. It is not a sufficient treatment when bleeding is caused by cancer of the uterus, since cancer cells may have grown into the deeper tissues of the uterus and can’t often be removed by the procedure.

Endometrial ablation is only performed on a nonpregnant woman who does not plan to become pregnantin the future. It should not be performed if the woman has an active infection of the genital tract. This treatment is not a first-line therapy for heavy bleeding and should only be considered only when medical and hormonal therapies have not been sufficient to control the bleeding.

How is endometrial ablation performed?

Prior to the procedure, a woman needs to have an endometrial sampling (biopsy) performed to exclude the presence of cancer. Imaging studies and/or direct visualization with a hysteroscope (a lighted viewing instrument that is inserted to visualize the inside of the uterus) are necessary to exclude the presence of uterine polyps or benign tumors (fibroids) beneath the lining tissues of the uterus. Polyps and fibroids are possible causes of heavy bleeding that can be simply removed without ablation of the entire endometrium. Obviously, the possibility of pregnancy must be excluded, and intrauterine contraceptivedevices (IUDs) must be removed prior to endometrial ablation.

Hormonal therapy may be given in the weeks prior to the procedure (particularly in younger women), in order to shrink the endometrium to an extent where ablation therapy has the greatest likelihood for success. The belief is the thinner the endometrium, the greater the chances for successful ablation.
To begin the procedure, the cervical opening is dilated to allow passage of the instruments into the uterine cavity. Different procedures have been used and are all similarly effective for destroying the uterine lining tissue. These include laser beam, electricity, freezing, and heating.

The choice of procedure depends upon a number of factors, including

• the surgeon’s preference and experience,

• the presence of fibroids, the size and shape of the uterus,

• whether or not pretreatment medication is given, and

• type of anesthesia desired by the patient.

The type of anesthesia required depends upon the method used, and some endometrial ablation procedures can be performed with minimal anesthesia during an office visit. Others may be performed in an outpatient surgery center.

What are the risks and complications of endometrial ablation?

Complications of the procedure are not common but may include:

• accidental perforation of the uterus,

• tears or damage to the cervical opening (the opening to the uterus), and

• infection, bleeding, and burn injuries to the uterus or intestines.

In very rare cases, fluid used to expand the uterus during the procedure can be absorbed into the bloodstream, leading to fluid in the lungs (pulmonary edema).

Some women may experience regrowth of the endometrium and need further surgery (see below).
Minor side effects from the procedure can occur for a few days, include cramping (like menstrual cramps), nausea, and frequent urination that may last for 24 hours. A watery discharge mixed with blood may be present for a few weeks after the procedure and can be heavy for the first few days.

What is the outlook after endometrial ablation?

The majority of women who undergo endometrial ablation report a successful reduction in abnormal bleeding. Up to half of women will stop having periods after the procedure. Yet, studies indicate the rate of failure (defined as bleeding or pain after endometrial ablation that required hysterectomy or reablation) was 16% to 30% at 5 years. Failure was most likely to occur in women younger than 45 years and in women with 5 or more children, prior tubal ligation, and a history of painful menstrual cramps. After endometrial ablation, 11% to 36% of women had a repeat ablation or other uterine-sparing procedure.

Although the procedure removes the uterine lining and typically results in infertility, it should not be considered as a birth control measure, because pregnancy can still occur in a small portion of the endometrium which remains or has regrown. In this case there may be severe problems with the pregnancy, and the procedure should never be performed if the woman may desire pregnancy in the future.

What is an endometrial biopsy?

The uterus (womb) is lined by a special type of tissue known as the endometrium. Endometrial biopsy, or endometrial sampling, is a technique of removing a piece of tissue from the inner lining of the uterus. The sample of tissue is analyzed under a microscope in the laboratory by a pathologist, a doctor with special training in diagnosis of diseases based upon tissue examination.

Why is endometrial biopsy done?

An endometrial biopsy is most often performed to help determine the cause of abnormal uterine bleeding. It can also be done to help evaluate the cause of infertility, test for uterine infections, and even monitor the response to certain medications.

Endometrial biopsy has many advantages over the more complicated procedure known as dilation and curettage (D&C), which is a more extensive removal of the uterine lining that requires dilation (stretching) of the cervical opening with special instruments. Unlike D&C, endometrial biopsy may be performed in the doctor’s office and typically does not require anesthesia or hospitalization.

Endometrial biopsy cannot be performed during pregnancy, and sometimes may not be recommended when certain other conditions are present, including cancer of the cervix or abnormal narrowing (stenosis) of the cervical opening.

How is an endometrial biopsy performed?

Endometrial biopsy is most often done in the physician’s office, but it can be performed on women in the hospital. The patient lies on the examining table in a position similar to that used for obtaining Pap smears. The doctor uses a speculum to open the vaginal canal and visualize the cervix, the opening to the uterus. During endometrial biopsy the doctor inserts a thin plastic or metal tubular device through the cervix into the uterus to remove a tiny piece of the inner lining tissue.

Usually no anesthesia is required, but taking a nonsteroidal anti-inflammatory medication (NSAID) 30 to 60 minutes prior to the procedure can help reduce cramping and pain. In some cases, a small amount of lidocaine anesthetic is inserted into the uterine cavity to minimize discomfort.

What are the risks of endometrial biopsy?

There are very few risks with endometrial biopsy. The leading risk is pain or cramping, but this typically subsides rapidly following the procedure. Other less common risks are feeling faint or light-headed, possible infection, bleeding, and rarely, perforation of the uterus.

What is a hysterectomy?

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A hysterectomy is a surgical procedure whereby the uterus (womb) is removed. This surgery for women is the most common non-obstetrical surgical procedure in the United States.

How common is hysterectomy?

Approximately 300 out of every 100,000 women will undergo a hysterectomy.

Why is a hysterectomy performed?

The most common reason hysterectomy is performed is for uterine fibroids. Other common reasons are:
• abnormal uterine bleeding (vaginal bleeding),

• cervical dysplasia (pre-cancerous conditions of the cervix),

• endometriosis, and uterine prolapse (including pelvic relaxation).

Only 10% of hysterectomies are performed for cancer. This article will primarily focus on the use of hysterectomy for non-cancerous, non-emergency reasons, which can involve even more challenging decisions for women and their doctors.

Uterine fibroids (also known as uterine leiomyomata) are by far the most common reason a hysterectomy is performed. Uterine fibroids are benign growths of the uterus, the cause of which is unknown. Although the vast majority are benign, meaning they do not cause or turn into cancer, uterine fibroids can cause medical problems. Indications for hysterectomy in cases of uterine fibroids are excessive size (usually greater than the size of a two-month pregnancy), pressure or pain, and/or bleeding severe enough to produce anemia. Pelvic relaxation is another condition that can require treatment with a hysterectomy.

In this condition, a woman experiences a loosening of the support muscles and tissues in the pelvic floor area. Mild relaxation can cause first degree prolapse, in which the cervix (the uterine opening) is about halfway down into the vagina. In second degree prolapse, the cervix or leading edge of the uterus has moved to the vaginal opening, and in third degree prolapse, the cervix and uterus protrude past the vaginal opening. Second and third degree uterine prolapse must be treated with hysterectomy.

A vaginal wall weakness such as a cystocele, rectocele, or urethrocele, can lead to symptoms such as urinary incontinence (unintentional loss of urine), pelvic heaviness, and impaired sexual performance. Urine loss tends to be aggravated by sneezing, coughing, jumping, or laughing. Childbearing is the most common risk factor for pelvic relaxation, though there may be other causes. Avoidance of vaginal birth and having a caesarean section doesn’t necessarily eliminate the risk of developing pelvic relaxation.

A hysterectomy is also performed to treat uterine cancer or very severe pre-cancers (called dysplasia, carcinoma in situ, or CIN III, or microinvasive carcinoma of the cervix). A hysterectomy for endometrial cancer (uterine lining cancer) has an obvious purpose, that of removal of the cancer from the body. This procedure is the foundation of treatment for cancer of the uterus.

Quick GuideFemale Sexual Dysfunction: Treatment for Women’s Sexual Disorders

What tests or treatments are performed prior to a hysterectomy?

A woman must have a pelvic examination, Pap smear, and a diagnosis prior to proceeding with a hysterectomy. Prior to having a hysterectomy for pelvic pain, women might undergo more limited (less extensive) exploratory surgery procedures (such as laparoscopy) to rule out other causes of pain. Prior to having a hysterectomy for abnormal uterine bleeding, women require some type of sampling of the lining of the uterus (biopsy of the endometrium) to rule out cancer or pre-cancer of the uterus. This procedure is called endometrial sampling. Also, pelvic ultrasounds and/or pelvic computerized tomography (CT) tests can be done to confirm a diagnosis. In a woman with pelvic pain or bleeding, a trial of medication treatment is often given before a hysterectomy is considered.

Therefore, a premenopausal (still having regular menstrual periods) woman whose uterine fibroids are causing bleeding but no pain is generally first offered medical therapy with hormones. Non-hormonal treatments are also available, such as tranexamic acid and more moderate surgical procedures, such as ablations (removal of the lining of the uterus). If she still has significant bleeding that causes major impairment to her daily life, or the bleeding continues to cause anemia (low red blood cell count due to blood loss), and she has no abnormality on endometrial sampling, she may be considered for a hysterectomy.

A postmenopausal woman (whose menstrual periods have ceased permanently) who has no abnormalities in the samples of her uterus (endometrial sampling) and still has persistent abnormal bleeding after trying hormone therapy, may be considered for a hysterectomy. Several dose adjustments or different types of hormones may be required to decide on the optimal medical treatment for an individual woman.

How is a hysterectomy performed?

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In the past the most common hysterectomy was done by an incision (cut) through the abdomen (abdominal hysterectomy). Now most surgeries can utilize laparoscopic assisted or vaginal hysterectomies (performed through the vagina rather than through the abdomen) for quicker and easier recovery. The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about two hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.

What are the types of hysterectomies?

There are now a variety of surgical techniques for performing hysterectomies. The ideal surgical procedure for each woman depends on her particular medical condition. Below, the different types of hysterectomy are discussed with general guidelines about which technique is considered for which type of medical situation. However, the final decision must be made after an individualized discussion between the woman and physician who best understands her individual situation.

Remember, as a general rule, before any type of hysterectomy, women should have the following tests in order to select the optimal procedure:

1. Complete pelvic exam including manually examining the ovaries and uterus.

2. Up-to-date Pap smear.

3. Pelvic ultrasound may be appropriate, depending on what the physician finds on examination.

4. A decision regarding whether or not to remove the ovaries at the time of hysterectomy.

5. A complete blood count and an attempt to correct anemia if possible.

Total abdominal hysterectomy

This is the most common type of hysterectomy. During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar on the abdomen may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy.

Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after attempts at non-surgical treatments. Clearly a woman cannot bear children after this procedure, so it is not generally performed on women who desire childbearing unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.

Laparoscopy-assisted vaginal hysterectomy

Laparoscopy-assisted vaginal hysterectomy (LAVH) is similar to the vaginal hysterectomy procedure described above, but it adds the use of a laparoscope. A laparoscope is a very thin viewing tube used to visualize structures within the abdomen. Certain women would be best served by having laparoscopy used during vaginal hysterectomy because it allows the upper abdomen to be carefully inspected during surgery. Examples of uses of the laparoscope would be for early endometrial cancer (to verify lack of spread of cancer), or if oophorectomy (removal of the ovaries) is planned.

Just as with simple vaginal hysterectomy without a laparoscope, the uterus must not be excessively large. The physician will also review the medical situation to be sure there are no special risks prohibiting use of the procedure, such as prior surgery that could have increased the risk for abnormal scarring (adhesions). If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular abdominal hysterectomy might be considered.

Supracervical hysterectomy

A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a “stump.” The cervix is the area that forms the very bottom of the uterus, and sits at the very end (top) of the vaginal canal (see illustration above). The procedure probably does not totally rule out the possibility of developing cancer in this remnant “stump.” Women who have had abnormal Pap smears or cervical cancerclearly are not appropriate candidates for this procedure. Other women may be able to have the procedure if there is no reason to have the cervix removed. In some cases the cervix is actually better left in place, such as some cases of severe endometriosis. It is a simpler procedure and requires less time to perform. It may give some added support of the vagina, decreasing the risk for the development of protrusion of the vaginal contents through the vaginal opening (vaginal prolapse).

Laparoscopic supra cervical hysterectomy

The laparoscopic supra cervical hysterectomy procedure is performed like the LAVH procedure, but the uterus is separated from the cervix, and the uterine tissue is removed through the laparoscopic incision. Recovery is generally faster than with other types of hysterectomy. Cervical preservation is less likely to result in menses (menstruation) as the inner lining of the cervix is usually cauterized.

Radical hysterectomy

The radical hysterectomy procedure involves more extensive surgery than a total abdominal hysterectomy because it also includes removing tissues surrounding the uterus and removal of the upper vagina. Radical hysterectomy is most commonly performed for early cervical cancer. There are more complications with radical hysterectomy compared to abdominal hysterectomy. These include injury to the bowels and urinary system.

What are complications of a hysterectomy?

Complications of a hysterectomy include infection, pain, and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.

What are the alternatives to a hysterectomy?

As mentioned above, a hysterectomy for conditions other than cancer is generally not considered until after other less invasive treatments are unsuccessful. There are also newer procedures, such as uterine artery embolization (UAE) or surgical removal of a portion of the uterus (myomectomy), that are being used to treat excessive uterine bleeding. Endometrial ablation and newer medications are also alternatives.

Should women who have had a hysterectomy continue to have Pap smears?

Any woman with a history of abnormal Pap smears should have Pap smears for the remainder of her life. This is because of the low, but real, chance that cervical cancer can recur at the surgical site where the cervix was removed.

In addition to women with a history of abnormal Pap smears, other women who require continued Pap smears are women with supracervical hysterectomy, in which the cervix was left in place. In this case, in contrast to the woman who has had hysterectomy for reasons of cervical cancer, the woman who has had supracervical hysterectomy will be able to follow the same screening guidelines as for other women who have not had surgery. For example, the physician may stop doing Pap smears at age 65 if the woman has been well-screened and has always had normal Pap smears.

Women who do not need to continue having Pap smears are those who have had vaginal hysterectomy or abdominal hysterectomy for benign (not cancer) reasons, such as uterine fibroids. If they have had normal Pap smears prior to the procedure, they need not continue to have Pap smears after their surgery.

Dilatation and curettage

Definition

Dilatation and curettage (D & C) is a gynecological procedure in which the cervix is dilated (expanded) and the lining of the uterus (endometrium) is scraped away.
Purpose

D & C is used to diagnose and treat heavy or irregular bleeding from the uterus. Possible reasons for abnormal uterine bleeding include:

• Hormonal imbalance. Often women with abnormal bleeding are first treated with hormones in an attempt to normalize bleeding. D & C may be used to determine the cause of bleeding if hormone treatment is ineffective.

• Endometrial polyps. Polyps are benign growths that may protrude from the uterus by a stem or stalk, usually to the endometrium or cervix. D & C may be used to diagnose polyps or to remove them.

• Uterine fibroids. Also called leiomyomas, fibroids are benign growths in the smooth muscle of the uterus. Abnormal bleeding is often the only symptom of fibroids. D & C is often used to diagnose fibroids and may be used to scrape away small tumors; additional surgery may be needed to remove more extensive growths.

• Endometrial hyperplasia (EH). EH is a condition where the endometrium grows excessively, becoming too thick and causing abnormal bleeding. Tissue samples procured during D & C can be assessed for early signs of cancer.

• Cancer. D & C may be used to obtain tissue for microscopic evaluation to rule out cancer. Women over the age of 40 are at an increased risk of developing endometrial cancer.

• Miscarriage, incomplete abortion, or childbirth. Abnormal bleeding may result if some of the products of pregnancy remain in the uterus after a miscarriage or induced abortion, or if parts of the placenta are not expelled naturally after childbirth. These retained products can be scraped out by D & C.

Description

D & C is usually performed under general anesthesia, although local or epidural anesthesia can also be used. Local anesthesia lessens risk and costs, but the woman will feel cramping during the procedure. The type of anesthesia used often depends upon the reason for the D & C.

During the procedure (which takes only minutes to perform), the doctor inserts an instrument called a speculum to hold open the vaginal walls, and then stretches the opening of the uterus (the cervix) by inserting a series of tapering rods, each thicker than the previous one, or by using other specialized instruments. This process of opening the cervix is called dilation.

Once the cervix is dilated, the physician inserts a spoon-shaped surgical device called a curette into the uterus. The curette is used to scrape away the uterine lining. One or more small tissue samples from the lining of the uterus or the cervical canal are sent for analysis by microscope to check for abnormal cells.
Although simpler, less expensive techniques such as a vacuum aspiration are quickly replacing the D & C as a diagnostic method, it is still often used to diagnose and treat a number of conditions.

Diagnosis/Preparation

If general anesthesia will be used, the patient will be instructed to refrain from eating and drinking for at least eight hours before the procedure. The doctor may order blood and/or urine tests to scan for certain abnormalities. Because opening the cervix can be painful, sedatives may be given before the procedure begins. Deep breathing and other relaxation techniques may help ease cramping during cervical dilation.

Aftercare

A woman who has had a D & C performed in a hospital can usually go home the same day or the next day. Many women experience backache and mild cramps after the procedure, and may pass small blood clots for a day or so. Vaginal staining or bleeding may continue for several weeks.

Most women can resume normal activities almost immediately. Patients should avoid sexual intercourse, douching, and tampon use for at least two weeks to prevent infection while the cervix is closing and to allow the endometrium to heal completely.

Risks

The primary risk after the procedure is infection. If a woman experiences any of the following symptoms, she should report them immediately to her doctor, who can treat the infection with antibiotics:
• fever

• heavy bleeding

• severe cramps

• foul-smelling vaginal discharge

D & C is a surgical operation that has certain risks associated with general anesthesia such as pulmonary aspiration and failed intubation. Rare complications include perforation of the uterus (which usually heals on its own) or puncture of the bowel or bladder (which requires further surgery to repair).

Extensive scarring of the uterus may occur after over-aggressive scraping during D & C, leading to a condition called Asherman’s syndrome. The major symptoms of Asherman’s syndrome are light or absent menstrual periods, infertility, and recurrent miscarriages. Scar tissue can be removed with surgery in most women, although approximately 20–30% of women will remain infertile after treatment.

Normal results

Removal of the uterine lining will normally cause no side effects, and may be beneficial if the lining has thickened so much that it causes heavy periods. The uterine lining soon grows again normally, as part of the menstrual cycle.

Morbidity and mortality rates

D & C has been associated with a 4–10% rate of postoperative complications.
Alternatives

There are a number of alternatives to D & C, depending on the reason for doing the procedure. The following are some examples of procedures that allow doctors alternative ways of evaluating, sampling, or treating disorders of the inner lining of the uterus:

•Expectant management of spontaneous abortion. D & C is the most commonly used method of treatment for incomplete abortion; one study showed that over 90% of women who visited hospital emergency rooms for incomplete spontaneous abortion were treated by D & C. Recent studies, however, have shown that expectant management (i.e., no active intervention) is a viable option for women who do not wish to undergo surgery and who are in otherwise good health. Up to 72% of women indicated that that expectant management of incomplete abortion was preferable to medical or surgical intervention.

•Endometrial biopsy. This procedure is similar to D & C in that a curette is used to obtain a sample of endometrial tissue. Little or no cervical dilation is necessary, however, because the curette used in endometrial biopsy is narrower. The cervix is numbed with a local anesthetic but the patient will still experience cramping.

•Vacuum scraping. A thin plastic tube attached to a suction machine is passed through the cervix and scraped along the endometrium. Vacuum scraping has been shown to have similar success in diagnosing uterine cancer as D & C. Local anesthesia is also used for this procedure.

•Hysteroscopy. A thin telescope called a hysteroscope is inserted through the cervix and used to view the inside of the uterus after it has been expanded with a liquid or gas. The view afforded by the hysteroscope can help to diagnose abnormal growths, accumulation of scar tissue, or other conditions.

•Hysterectomy . A total hysterectomy permanently removes the uterus and cervix. This procedure is generally recommended only if a woman no longer desires to have children and no other forms of treatment have been successful. Most hysterectomies are done to treat uterine fibroids and endometriosis (a condition in which the endometrium grows outside of the uterus).

Oophorectomy and salpingoophorectomy (removal of the ovaries or Fallopian tubes)

Oophorectomy is the surgical removal of the ovary(s), while salpingoophorectomy is the removal of the ovary and its adjacent Fallopian tube. These two procedures are performed for ovarian cancer, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Occasionally, women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventive (prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast. Current recommendations are that the fallopian tubes should be removed during hysterectomy even if the ovaries are preserved. This is done to decrease the lifetime risk of ovarian cancer, which can arise from the fallopian tubes in up to 25% of case.

• Tubal Ligation

• Vulvectomy

• Cystectomy

• Salpingectomy