Dilation and Curettage (D&C) is a common gynecological procedure that carries the potential risk of developing Asherman’s Syndrome (AS). This acquired uterine condition involves the formation of internal scar tissue, or intrauterine adhesions, which can significantly affect reproductive health. The connection between the D&C procedure and the subsequent development of this scarring means that understanding the statistical likelihood of this complication is a natural concern for anyone undergoing the surgery. This information is crucial for accurately framing the risk and informing discussions with healthcare providers.
Defining Asherman’s Syndrome and D&C
Asherman’s Syndrome (AS) is characterized by the formation of scar tissue, or intrauterine adhesions, within the uterine cavity and sometimes the cervix. These adhesions cause the walls of the uterus to stick together, which can partially or completely block the cavity. Scarring occurs when the basal layer of the endometrium, the tissue lining the uterus, is traumatized and then heals improperly by forming fibrotic tissue. This damage reduces the functional space within the uterus and prevents the normal monthly regeneration of the endometrial lining.
Dilation and Curettage (D&C) is a procedure where the cervix is gently opened, or dilated, and tissue is removed from the uterine lining using a surgical instrument or a suction device. It is a frequent procedure performed for various reasons, including the diagnosis of abnormal uterine bleeding or the removal of tissue following a miscarriage, incomplete abortion, or delivery. The mechanical removal of tissue during a D&C can inadvertently cause trauma to the sensitive uterine lining, which is the mechanism that can lead to the formation of scar tissue. More than 90% of Asherman’s Syndrome cases are estimated to happen after a pregnancy-related D&C procedure.
Quantifying the Risk: Incidence Rates After D&C
Determining the exact frequency of Asherman’s Syndrome after a D&C is challenging, as the incidence rates vary significantly depending on the study population and the specific reason for the procedure. Following a single, routine D&C, the risk of developing the condition is considered relatively low. Some estimates suggest that scarring occurs in approximately 1% of all D&C procedures.
However, the risk dramatically increases when the procedure is performed in specific clinical contexts, leading to a wide range of reported incidence rates. For instance, the risk has been estimated to be around 13% for women undergoing a D&C for a first-trimester termination of pregnancy. The incidence can rise to 30% following a late spontaneous abortion or miscarriage. This variability underscores that the condition is not common across all D&C procedures, but rather concentrated among those performed for certain indications and high-risk subgroups.
Procedural Factors That Influence Risk
The context of the D&C procedure is the most significant factor determining an individual’s risk of developing intrauterine adhesions. The uterus is particularly vulnerable to damage when it has been recently pregnant, which is why a D&C performed after a pregnancy-related event carries a notably elevated risk. This includes procedures done for a missed or incomplete miscarriage, incomplete abortion, or to remove retained products of conception (RPOC) after delivery.
The timing of the procedure also affects the likelihood of scarring. A D&C performed two to four weeks after childbirth, often to remove a retained placenta, has been associated with an incidence rate as high as 25%. This heightened vulnerability is thought to be due to the trauma the uterine lining sustained during the recent pregnancy and delivery.
The technique used during the procedure is another factor influencing the risk of damage to the basal layer of the endometrium. Minimizing trauma is beneficial. Repeating the D&C procedure significantly increases the overall risk of developing Asherman’s Syndrome. Patients who have had three or more uterine instrumentations face a substantially higher chance of developing the condition.
Recognizing Symptoms and Treatment Options
Recognizing the signs of Asherman’s Syndrome is often the first step toward diagnosis, especially if symptoms appear after a D&C or other uterine surgery. The primary symptom is a change in the menstrual pattern, most commonly a reduction in the volume of menstrual flow (hypomenorrhea), or the complete absence of periods (amenorrhea). Some individuals may experience cyclical pelvic pain without corresponding bleeding, which occurs when menstrual blood is trapped within the scarred uterine cavity.
AS can also lead to difficulties with reproduction, including infertility and recurrent miscarriages, because the scarred environment prevents proper embryo implantation. Diagnosis is typically confirmed using imaging techniques like transvaginal ultrasound or hysterosalpingography. The gold standard for diagnosis is hysteroscopy. This procedure involves inserting a thin, lighted camera through the cervix to allow a direct visual assessment of the uterine cavity and the extent of the adhesions.
The main treatment for Asherman’s Syndrome is hysteroscopic lysis of adhesions. This surgical procedure uses specialized instruments inserted through the hysteroscope to carefully cut and remove the scar tissue, aiming to restore the normal shape and volume of the uterine cavity. Following the removal of the adhesions, a small device, such as a balloon, may be temporarily placed inside the uterus. Estrogen therapy is often prescribed to encourage the healthy regrowth of the endometrial lining and prevent the re-formation of scar tissue.