Diagnostic Curettage

Why is it done?

The purpose is examination in pathology of a tissue sample taken from the lining of the womb. The situation in which it most often comes up is abnormal bleeding from the womb. Assessment of the inside of the womb may also be needed when investigating reproductive problems.

How is the inside of the womb assessed today?

Hysteroscopy is direct visualisation of the cavity of the womb with miniaturised endoscopic instruments. Guidelines state that this can be done as an outpatient, without an operating theatre, intravenous sedation or general or regional anaesthesia.

What matters about this approach is that the inside of the womb is assessed by seeing rather than blindly, and that where necessary the sample can be taken from the right point.

Procedures that can be done as an outpatient

Advances in instruments have made it possible not only to make a diagnosis but also to carry out some procedures as an outpatient:

• Removing a polyp inside the womb
• Removing fibroids close to the lining of the womb
• Ablation of the lining of the womb
• Removing pregnancy tissue remaining in the womb
• Removing a lost intrauterine device

For removing a polyp, the guideline recommends that mechanical tissue-removal systems be preferred to small bipolar electrodes.

What being done as an outpatient achieves

In a randomised study comparing it with the procedure under general anaesthesia, the following differences were found in favour of outpatient hysteroscopy:

• Time to getting up: 0 minutes — 105 minutes under general anaesthesia
• Return to the pre-procedure state: 2 days — 3 days under general anaesthesia
• Time away from work: 0.8 days — 3.3 days under general anaesthesia
• Lower loss of income and travel costs
• People's ratings of their experience of the procedure were found to be high and equivalent with both methods

Pain: a subject that needs to be discussed openly

In whom may it be more painful?

This is difficult to predict in advance; but the guideline states that the person should be told beforehand that the procedure may be more painful and difficult in the following situations:

• Having experienced faintness because of pain during periods
• Having experienced severe pain or anxiety during previous vaginal examinations — including having a smear taken
• Traumatic experiences, particularly a history of sexual violence

What the guideline says about pain management

• Taking a painkiller by mouth an hour before the appointment is recommended.
• When a vaginoscopic approach (carried out without an examination instrument) is used, routine local anaesthesia should not be given. It should be considered if the use of a speculum (the instrument used in an examination) is planned — for example if dilatation may be needed because of narrowing of the cervix or the use of a wider instrument.
• Conscious sedation should not be used routinely.
• Saline should be delivered at the lowest pressure that gives an adequate image.
• The use of music and virtual reality headsets has been shown to reduce pain and anxiety.

Where and with whom should it be done?

• The procedure should not be carried out in an operating theatre — that environment is expected to create anxiety and removes what being done as an outpatient achieves.
• There should be an adequately sized, properly equipped procedure room, with an adjacent private changing area and toilet. Resuscitation facilities should be ready.
• There should be at least two support staff: at least one nurse and one health care assistant. One member of staff should act as an advocate who stays with the person throughout the procedure, explaining and supporting.

Your rights

The points the guideline stresses:

• Written information should be given before the appointment: what the procedure is, its benefits and its risks including pain, advice on painkillers, the care options and contact details you can use.
• You should be told that other settings and anaesthetic options exist — general or regional anaesthesia, intravenous sedation.
• If treatment can also be carried out in the same session, this should be stated clearly in the information given.
• You can ask for the procedure to be stopped; if you are anxious, the appointment can be rearranged according to the anaesthetic method you prefer.
• If you want someone close to you to be with you, this should be accommodated unless infection control prevents it.