Asherman’s syndrome is an acquired uterine condition where scar tissue, known as adhesions, forms inside the uterus. This scarring can cause the uterine walls to thicken and fuse together, reducing the uterine cavity’s volume and interfering with normal reproductive function. This condition is considered rare, but it can sometimes go undiagnosed in individuals who do not experience clear symptoms.
Causes and Risk Factors
The formation of intrauterine adhesions is most commonly a complication of uterine surgery. A dilation and curettage (D&C), performed after a miscarriage or to remove retained placental tissue following childbirth, is the leading cause. Trauma to the uterine lining during such procedures can trigger the formation of scar tissue as the body heals.
The risk of developing Asherman’s syndrome is higher when these surgical interventions occur in a post-pregnancy uterus. Hormonal shifts after pregnancy can affect the uterine environment, making it more susceptible to scarring. There is a chance of developing the condition if a D&C is performed two to four weeks postpartum for a retained placenta.
Other events can also lead to uterine scarring. Severe infections of the uterine lining (endometritis) can cause inflammation that results in adhesions. Uterine surgeries unrelated to pregnancy, such as a myomectomy for fibroid removal or a cesarean section, also carry a risk of causing the trauma that leads to the condition.
Identifying the Symptoms
A frequent indicator of Asherman’s syndrome is a change in menstrual patterns. Many individuals experience a significant reduction in menstrual flow (hypomenorrhea) or a complete cessation of periods (amenorrhea). These changes occur because scar tissue has replaced the uterine lining that is shed during menstruation.
Some individuals experience cyclical pelvic pain or cramping with little to no bleeding. This can happen when adhesions block the cervix or upper uterus, trapping menstrual blood and preventing it from exiting the body. This blockage can cause discomfort and a sensation of pressure.
The condition impacts fertility, as scar tissue can prevent a fertilized egg from implanting in the uterine wall. For those who do conceive, adhesions can interfere with fetal and placental development, increasing the risk of recurrent pregnancy loss or stillbirth.
The Diagnostic Process
Diagnosing Asherman’s syndrome begins with a review of a patient’s medical and surgical history, focusing on previous pregnancies and uterine procedures. The patient’s reported symptoms, such as menstrual changes or conception difficulties, provide initial clues. A physical examination is often performed, though it is uncommon for adhesions to be detected this way.
The definitive method for diagnosis is a hysteroscopy, a procedure to visualize the inside of the uterus. It involves inserting a thin, lighted instrument (a hysteroscope) through the cervix to directly inspect the uterine cavity for the presence, location, and extent of scar tissue.
Other diagnostic tools can also assess the uterine lining. A saline infusion sonohysterography (SHG) uses a sterile saline solution and a transvaginal ultrasound to outline the uterine cavity and reveal abnormalities. A hysterosalpingogram (HSG) is an X-ray that uses contrast dye to highlight the uterine cavity and fallopian tubes, showing irregularities caused by adhesions.
Treatment Approaches
The primary treatment is an operative hysteroscopy, a minimally invasive surgery to remove scar tissue and restore the uterine cavity’s shape. Performed under general anesthesia, the goal is to resect the adhesions without causing additional trauma to the healthy uterine lining.
During the operative hysteroscopy, a surgeon inserts a hysteroscope with small surgical instruments into the uterus. Using instruments like micro-scissors or energy-based devices, the surgeon cuts and removes the bands of scar tissue. This process, known as adhesiolysis, separates the fused uterine walls and reopens the cavity.
The surgery’s complexity and duration depend on the density and extent of the adhesions. In cases of extensive scarring, the procedure requires a high degree of precision to minimize the risk of uterine perforation or further damage to the endometrium. This tissue is needed to regenerate for future menstruation and pregnancy.
Post-Treatment and Future Outlook
Following surgery, medical interventions are often used to prevent adhesions from reforming. A common practice is the temporary placement of a small inflatable balloon or catheter inside the uterus. This device keeps the uterine walls separated during the initial healing phase.
To promote the regrowth of a healthy endometrium, a course of hormone therapy is prescribed. This usually involves estrogen to stimulate the proliferation of endometrial tissue, followed by progesterone to mature the lining. This hormonal support helps re-establish a normal menstrual cycle.
The prognosis after treatment varies. Many individuals see a return of regular menstrual cycles. However, the outlook for fertility depends on the initial severity of the adhesions and the quality of the remaining endometrium. While treatment can restore the uterus, the chances of a successful pregnancy may still be affected, and some individuals may require further fertility assistance.