What is Asherman Syndrome?

Asherman syndrome, also known as intrauterine adhesions or intrauterine synechiae, is a condition where scar tissue forms in the uterus or the cervix.

What Causes Asherman Syndrome?

Asherman syndrome usually develops after a medical procedure called dilation and curettage, which is often done for reasons like ending a pregnancy, managing a miscarriage, or removing leftover placental tissue after childbirth. This condition can happen whether there was bleeding after childbirth or a pregnancy termination or not.

Sometimes, Asherman syndrome can occur after dilation and curettage for reasons unrelated to pregnancy, like controlling heavy bleeding, checking for endometrial cancer, or removing polyps from the uterus. It can also happen after a surgery to get rid of uterine fibroids.

In some cases, the goal is to create adhesions (scar tissue) in the uterus to help manage heavy and persistent menstrual bleeding. This is achieved through specific procedures that damage the lining of the uterus causing scars to form.

In developing countries, infections such as schistosomiasis or genital tuberculosis can also cause Asherman syndrome.

Risk Factors and Frequency for Asherman Syndrome

Asherman syndrome is a condition that might not be easily recognized in women who are not trying to get pregnant. These women might experience light periods, known as hypomenorrhea, but may not realize these are symptoms of a deeper problem. Because this condition can’t be detected by routine checkups or ultrasound scans, it’s often underdiagnosed. The following groups of women have an increased risk of developing Asherman syndrome:

Up to 13% of women ending a pregnancy in the first trimester.
30% of women who undergo a dilation and curettage (D and C) procedure following a late miscarriage.
Women with a placental abnormality called placenta increta. This is because the placenta sticks to deeper layers within the uterus, making it more difficult to remove.
Up to 23.4% of women who undergo procedures two to four weeks after the initial procedure following a vaginal delivery or miscarriage.
Women who have multiple procedures due to bleeding or elective termination of pregnancies.

Additionally, Asherman syndrome is found in:

1.5% of women tested with a hysterosalpingogram (HSG) due to infertility.
Between 5 and 39% of women with recurrent miscarriages.
31% of women after the initial hysteroscopic resection of leiomyoma, a type of uterine fibroid.
Up to 46% after the second hysteroscopic resection.

Signs and Symptoms of Asherman Syndrome

Asherman syndrome is a condition that affects menstruation. Some people with this syndrome might experience lighter periods or may not menstruate at all (amenorrhea). However, others might still have regular menstrual cycles, depending on the extent of the condition’s effect inside their body. There are cases in which individuals do not have periods but suffer from intense menstrual pain (dysmenorrhea) around the time their period would typically occur. This pain might be a sign that their menstrual cycle is proceeding normally, but the flow is blocked by adhesions near or within the cervix. These adhesions can also lead to recurrent miscarriages or infertility, due to a lack of healthy endometrial tissue and poor blood supply.

Testing for Asherman Syndrome

If a patient with secondary amenorrhea, or absent periods, does not experience a menstrual cycle even after receiving estrogen-progesterone treatments, and their brain and ovary function are normal, then they may be diagnosed with Asherman’s syndrome. This is a condition where the inside of the uterus develops scar tissue.

Initial tests for Asherman’s might include two-dimensional sonography, which uses sound waves to create pictures of the inside of the body, saline sonography which uses saline solution to expand the uterus making it easier to detect abnormalities, or hysterosalpingography where a dye is injected into the uterus and fallopian tubes before taking x-rays. These diagnostic methods are still not perfect, as they only catch the disease around 75% of the time.

The preferred way to confirm Asherman’s syndrome and assess how severe it is, is through hysteroscopy. This is a procedure where a doctor uses a thin, lighted tube to examine the uterus, and can also treat the disease at the same time. If the uterus is completely blocked with scar tissue, an MRI, which uses magnetic fields and radio waves to create detailed images of the body, may also be necessary.

Treatment Options for Asherman Syndrome

Asherman syndrome, a condition where scar tissue forms in the uterus, should be managed by an expert surgeon skilled in hysteroscopy, a procedure that uses a small camera to examine the uterus. The surgeon might use ultrasound or laparoscopy (surgery assisted with a camera) to guide the procedure. Often, the scar tissue is cut away with scissors, although other methods may be used with caution to avoid further complications.

The patient might be given estrogen (a female hormone) before and after surgery, either orally, through the skin, or through injections. Estrogen might help reduce scar formation after the surgery and encourage the normal lining of the uterus to grow.

During the surgery, devices can be placed inside the uterus to prevent its walls from sticking together, which can lead to scarring. However, these devices should be monitored attentively to avoid the thinning of the uterine wall due to pressure.

In the future, experimental treatments involving infusing the patient’s stem cells into the uterus might help to rebuild the lining of the uterus. These stem cells can be taken from the patient’s blood cells or fresh or freeze-dried tissue from the placenta or other sources. However, more research is needed to confirm the safety and effectiveness of these treatments.

Gels containing a man-made version of an enzyme called hyaluronidase might also be useful in reducing the recurrence of scars in the uterus. However, the benefit of these gels is still being evaluated.

Lastly, a follow-up examination one to two weeks after surgery can help identify any new scar formations at an early stage. This enables more timely treatment, potentially reducing the chance of their worsening.

Problems with the thyroid
Issues with the hypothalamus
Problems with the pituitary gland
Ovarian or adrenal tumors that produce too much male hormone
Polycystic ovary syndrome, a condition involving unbalanced female hormone levels
Pelvic inflammatory disease, an infection of the female reproductive organs
Cervical stenosis, narrowing of the cervix
Premature menopause, occurring before the age of 40

What to expect with Asherman Syndrome

The odds of getting pregnant and giving birth after surgery can be lower for individuals with moderate to severe illness. However, these odds may increase if the surgeons can reconstruct the cavity and periods return. Even though the inner lining of the uterus might start looking normal after multiple surgeries, it may take a while for a normal tissue lining to develop, or it may not happen at all.

Possible Complications When Diagnosed with Asherman Syndrome

Asherman’s syndrome is a condition that can lead to recurring loss of pregnancy or abortions, even after medical treatment and surgery. Moreover, the reformation of these scars can happen even after they have been surgically removed.

Although Asherman’s syndrome may decrease the risk of endometrial cancer compared to the average population, it doesn’t entirely rule out the possibility. Women with Asherman’s syndrome can develop endometrial cancer before or after menopause. Typical signs, such as unusual or early bleeding and a thickening of the endometrium, might be overlooked due to the scar tissue or blockage in the cervix. Therefore, it could be beneficial for these women to have regular sonogram checks to track changes in the endometrium.

This syndrome might also lead to complications during pregnancy, such as early labour, low birth weight, and certain issues with the placenta like it being retained or embedded into the uterine wall (a condition called placenta accreta).

Potential Complications with Asherman’s syndrome:

Recurring loss of pregnancy or abortions
Scars reforming after removal
Development of endometrial cancer before or after menopause
Misdiagnosis of cancer due to obscured symptoms
Early labour
Low birth weight
Issues with the placenta such as it being retained or embedded into the uterine wall (placenta accreta)

Preventing Asherman Syndrome

While it’s hard to completely prevent Asherman syndrome, it’s really important for patients to understand how to use birth control and know the options available to them. This can help reduce the number of legal abortions and minimize the need for curettage, a procedure that can lead to Asherman syndrome. Basically, better education on contraception can help decrease the risk of this condition.