Hysteroscopy and Dilation and Curettage – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Dilation and curettage (D&C) which is a procedure performed under general anaesthetic in which the lining of the uterus (the endometrium) is biopsied or removed by scraping (curettage).
  • Hysteroscopy in the investigation and management of heavy menstrual bleeding

Status

Eligibility Criteria

  • The CCGs will commission the use of hysteroscopy in the management of Heavy Menstrual Bleeding [HMB] in line with NICE guidance [CG44].
  • The CCGs will not commission the use of dilatation and curettage [D&C] in the management of HMB which is in line with NICE Guidance [CG44]

Hysteroscopy in management of HMB

  • Patients will undergo hysteroscopy in the investigation and management of heavy menstrual bleeding only:
    • when it is carried out as an investigation for structural and histological abnormalities where ultrasound has been used as a first line diagnostic tool and where the outcomes are inconclusive, for example to determine the exact location of a fibroid or the exact nature of the abnormality;
    • where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be considered immediately prior to the ablative procedure to ensure correct placement of the device.

D&C

  • NICE guidance recommends that D&C is NOT used:
    • as a diagnostic tool for heavy menstrual bleeding
    • as a therapeutic treatment for heavy menstrual bleeding.

NICE Heavy Menstrual Bleeding (CG44) – Full Guideline Consultation January 2007:updated August 2016 https://www.nice.org.uk/guidance/cg44

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

Ultrasound (1st line) or hysteroscopy [with or without biopsy] (2nd line) are recommended as diagnostic techniques to investigate uterine bleeding disorders1, 2, 3 NICE guidance indicates that D&C alone should not be used for diagnostic purposes.

Hysteroscopy with biopsy is also the preferred technique to remove polyps and other benign lesions, as it allows targeted removal. If a tissue sample is required and there is no lesion visible on a scan then an endometrial biopsy may be done (using a small hollow plastic tube that removes a small plug of tissue on gentle suction).

There is limited evidence on the effectiveness of D&C in the management of menorrhagia. The one study identified by NICE showed that any effect was temporary4. NICE guidance states that D&C should not be used as a therapeutic treatment.

Evacuation of retained products of conception (ERPC): where surgical evacuation after incomplete miscarriage or delivery is clinically indicated over medical management and watchful waiting, vacuum aspiration has superceded D&C as it is quicker, safer, easier and less painful.

Gestational trophoblastic disease: Suction/vacuum curettage is the preferred method of evacuation irrespective of uterine size in patients with suspected hydatidiform mole who want to preserve fertility.

References

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA15 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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