Dilatation and curettage in the evaluation of abnormal uterine bleeding: histopathologic findings and the cost/benefit relation

Abstract

Objetivo: avaliar criticamente os achados histopatol??gicos e a rela????o custo/benef??cio da dilata????o e curetagem uterina (DC) no rastreio do sangramento uterino anormal (SUA). M??todo: an??lise retrospectiva dos resultados histopatol??gicos de 542 DC praticadas por SUA na Disciplicna de Ginecologia da Faculdade de Ci??ncias M??dicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), de janeiro de 1984 a janeiro de 1994. As pacientes foram divididas em dois grupos: Grupo 1 - pacientes com idade igual ou inferior a 50 anos (n=385) e Grupo 2 - pacientes com mais de 50 anos (n=157). Foram exclu??dos desse estudo os casos de curetagens de urg??ncia. Todas as curetagens foram realizadas sob narcose. O tempo m??dio de interna????o foi de tr??s dias. Considerou-se resultado patol??gico negativo quando o laudo histopatol??gico mostrou endom??trio tipo proliferativo, secretor, atr??fico ou iatrog??nico. Este ??ltimo termo refere-se a endom??trio sob poss??vel influ??ncia de medica????o hormonal. Considerou-se resultado patol??gico positivo quando o laudo histopatol??gico evidenciou algum tipo de les??o. Resultados: no Grupo 1 encontrou-se resultado patol??gico negativo em 50,2 por cento dos casos, resultado patol??gico positivo em 39,7 por cento dos casos e material insuficiente para diagn??stico (MIPD) em 10,1 por cento dos casos. P??lipo endometrial e mioma submucoso foram observados em apenas 5,5 por cento e 4,4 por cento, respectivamente. O c??ncer foi de observa????o incomum nesse grupo, sendo encontrado o adenocarcinoma do endom??trio (ACE) em apenas 1,3 por cento dos casos (n=5), numa rela????o de 77 DC para um ACE.No Grupo 2 observou-se resultado patol??gico negativo em 38,3 por cento dos casos, resultado patol??gico positivo em 38,1 por cento dos casos e MIPD em 23,6 por cento dos casos. P??lipo endometrial e mioma submucoso foram diagnosticados em somente 5,1 por cento e 0,6 por cento, respectivamente. Les??es malignas foram encontradas em 12 por cento dos casos, sendo 9,5 por cento (15 casos) de ACE, mostrando rela????o de um ACE para 10 DC. Conclus??es: consoante o conhecimento atual sobre a etiopatogenia do SUA este estudo mostrou que a DC diagn??stica tradicional tem baixa acur??cia na avalia????o daquele sangramento e rela????o custo/benef??cio incompat??vel com a medicina atual. Portanto, n??o deve ser o exame de primeira escolha. Atualmente, a DC n??o tem mais um papel significante no rastreio do SUA como tinha h?? alguns anos.Purpose: to critically evaluate the histopathologic findings and the cost/benefit relation of dilatation and uterine curettage (D&C) in the evaluation of the abnormal uterine bleeding (AUB). Method: retrospective analysis of the histopathological findings in 542 D&C performed for AUB in the Department of Gynecology of the Faculdade de Ci??ncias M??dicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), between January 1984 and January 1994. The patients were divided into two groups: Group 1 - patients ??50 years (385 D&C) and Group 2 ?? patients >50 years (157 D&C). Cases of urgency curettage were excluded from the study. All the curettages were accomplished under narcosis. The mean hospitalization lenght was three days. A histopa-thological finding of proliferative, secretory, atrophic or iatrogenic type endometrium was considered a negative pathological result. The term iatrogenic refers to the endometrium under possible influence of hormonal medication. When the histopathological finding evidenced some lesion, this was considered a positive pathological result. Results: in Group 1 there was a negative pathological result in 50.2% of the cases, positive pathological result in 39.7% of the cases, and insufficient material for diagnosis (IMD) in 10.1% of the cases. Endometrial polyp and submucosal leiomyoma were found in only 5.5% and 4.4%, respectively. Cancer was an uncommon observation in that group, endometrial adenocarcinoma (EAC) (five cases) being found in only 1.3% of the cases, in a relation of 77 D&C to one EAC. In Group 2, a negative pathological result was observed in 38.3% of the cases, positive pathological result in 38.1% of the cases and IMD in 23.6% of the cases. Endometrial polyp and submucosal leiomyoma were found only in 5.1% and 0.6%, respectively. Malignant lesions were found in 12% of the cases EAC being 9.5% (15 cases), showing a relation of one EAC to 10 D&C. Conclusions: according to the current knowledge on the etiology of AUB, this study showed that traditional diagnostic D&C has low accuracy in the evaluation of AUB and a cost/benefit relation incompatible with current medicine. Therefore, it should not be the examination of first choice. Considering, however, that EAC was found in one of each 10 D&C in women >50 years with a complaint of uterine bleeding, D&C can be indicated with more liberality in that group, if hysteroscopy with directed biopsy is not available. Nowadays, D&C does not play such a significant a role in the diagnosis of AUB as it did some years ago. However, the procedure is still indicated in some situations and it cannot be abandoned, and its indication should obey restricted criteria