Asherman's Syndrome Causes, Symptoms & Treatment
Asherman’s syndrome, also known as intrauterine adhesions, is a condition where the cavity of the uterus develops scar tissue (adhesions). The symptoms, extent of the adhesions, effect on the uterine cavity and clinical importance vary greatly.
Serving communities throughout Greater Boston, the gynecologic surgeons at Newton-Wellesley Hospital’s Minimally Invasive Gynecological Surgery (MIGS) can provide patients with screenings and treatment for Asherman’s Syndrome, which involves breaking up the scar tissue and preventing re-growth of scar tissue. Depending on the goal of treatment, success can vary. The majority of women resume menses (get their period) again.
To learn more about Asherman’s Syndrome symptoms, causes, tests and treatment options, continue reading. If you would like to arrange for a consultation and evaluation with one of our surgeons contact MIGS today.
What causes Asherman’s syndrome?
Intrauterine adhesions are most commonly related to procedures involving the uterus after pregnancy, such as a D&C. Scar tissue can also be related to instrumentation of the non-pregnant uterus and to an infection involving the uterus.
Instrumentation of the uterus related to pregnancy can include:
- Curettage for post-partum complications such as post-partum hemorrhage or retained placenta
- Dilation and evacuation (D&E) or dilation and curettage (D&C) for a miscarriage, abortion, or retained products of conception.
Instrumentation of the uterus not-related to pregnancy can include:
- D&C for heavy bleeding
- Other uterine surgery
Infections involving the uterus can include:
- Pelvic infection after a delivery, miscarriage or abortion
- Pelvic tuberculosis (TB) is a common cause of intrauterine adhesions in the developing world.
Although it is uncommon, some women have Asherman’s syndrome without ever having had any of the above predisposing factors.
What symptoms does Asherman’s syndrome cause?
Asherman’s syndrome can be asymptomatic (without symptoms). Symptoms that women may have with intrauterine adhesions include:
- Recurrent pregnancy loss (miscarriage)
- Menstrual irregularities such as very light periods (hypomenorrhea) or absence of periods (amenorrhea). This can occur if scar tissue replaces the normal endometrium, so there is less endometrium shed during menses. It also can occur if scar tissue blocks the outflow of the menstrual blood.
- Cyclic pelvic pain can occur if scar tissue blocks the outflow of the menstrual blood, causing uterine cramping and pelvic discomfort or pain.
How is Asherman’s syndrome diagnosed?
Although some tests, such as a hysterosalpingogram (HSG) - injection of dye into the uterine cavity followed by an X-ray - or a sonohysterogram -injection on fluid into the uterine cavity while looking with an ultrasound - may suggest the presence of intrauterine adhesions, the gold standard is to directly look at the uterine cavity and scar tissue using hysteroscopy.
At the MIGS center, the physician can perform a hysteroscopy in the office in order to directly visualize the uterine cavity and the extent and nature of any adhesions. Depending on the extent and type of scar tissue, it may be possible to break up some of the scar tissue at the time of initial diagnosis.
The most common type of adhesions are bands of scar tissue that span from one wall of the uterus to another. Scar tissue is less commonly flat; in this case, the scar tissue can replace the normal lining of the uterus, but the uterine cavity remains open.
Transvaginal ultrasound can be used to evaluate and measure the endometrial stripe (thickness of the endometrial lining).
An endometrial biopsy is sometimes performed to sample the lining to the uterus as a way of determining if any normal endometrium is present.
Is there a classification system of Asherman’s syndrome?
At the MIGS center, we use the American Fertility Society/American Society for Reproductive Medicine classification of intrauterine adhesions.
There are three stages of disease: Stage I (mild), Stage II (moderate) and Stage III (severe). The stage of disease is determined by the extent of the endometrial cavity involved (adhesions throughout the uterus or just in a small area), the type of adhesions (filmy or dense) and the menstrual pattern.
For example, mild disease can involve just a few bands of scar tissue in a woman with normal periods. Severe disease can be characterized by complete obliteration and occlusion (obstruction) of the endometrial cavity and no menstrual bleeding.
What are treatment options for Asherman’s syndrome?
There are no studies that clearly demonstrate that one way of treating intrauterine adhesions is better than another. In general, the treatment involves breaking up the scar tissue and preventing re-growth of scar tissue. If a woman has intrauterine adhesions, but does not have any symptoms (such as cyclic pelvic pain) and is not interested in fertility, there is no medical reason why intrauterine scar tissue needs to be treated.
The treatment of Asherman’s syndrome involves two stages:
1. Hysteroscopic lysis of adhesions (removal of scar tissue)
The first step in the treatment of intrauterine adhesions is to break up the scar tissue, open the uterine cavity and identify the tubal ostia (openings of the fallopian tubes into the uterus). At the MIGS center, we believe that breaking up the scar tissue under direct visualization, without using any energy source (such as laser or electricity) is the preferred, least traumatic way to break up the scar tissue.
All procedures are performed using a hysteroscope. The surgery can be performed in the office or in the operating room, depending on the patient and the extent of her adhesions. All surgery is day surgery, with a rapid recovery and minimal need for post-operative pain medication.
If the scar tissue is thin and filmy, it can be broken up bluntly using the hysteroscope. If the adhesions are thick and dense, scissors are used to cut the scar tissue. The goal of the surgery is to completely open up the uterine cavity, and be able to identify both tubal ostia. Ultrasound is sometimes used to help guide the lysis of adhesions
2. Preventing reformation of the scar tissue after the initial lysis of adhesions
One of the challenges with Asherman’s syndrome is that once the scar tissue is removed, it frequently returns. Although there are several different techniques that physicians use to prevent reformation of scar tissue, none have been shown to clearly work better than another. Techniques include the use of estrogen post-procedure, repeat office hysteroscopies to break up scar tissue as it forms, and placement of a balloon in the uterine cavity after lysis of adhesions:
- Oral Estrogen: At the MIGS center, we give women a course of estrogen (typically for 30 days) after they undergo a hysteroscopic lysis of adhesions as a way of promoting growth of normal uterine lining and helping prevent the regrowth of the scar tissue.
- Repeat office hysteroscopy: We recommend a repeat office hysteroscopy seven to 14 days after the initial hysteroscopic lysis of adhesions. During this procedure, a small flexible hysteroscope is used to identify any scar tissue that may have reformed and the hysteroscope is used to bluntly break up this scar tissue. This cycle is repeated every seven to 14 days until no re-growth of scar tissue is seen, but typically not more than three times total.
- Placement of an intrauterine balloon: Some practitioners place an inflated balloon or an intrauterine device (IUD) inside the uterine cavity after the initial lysis of adhesions to try to prevent re-growth of scar tissue.
- Transvaginal ultrasound can be used to evaluate and measure the endometrial stripe (thickness of the endometrial lining). This can be used as an indication of how much healthy endometrium there is.
- An endometrial biopsy is sometimes performed to sample the lining to the uterus as a way of determining if there is any normal endometrium in the uterus.
What is the typical outcome after treatment?
Depending on the goal of treatment, success can vary. The majority of women resume menses (get their period) again.