PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.surgery, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus