Asherman's Syndrome

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Asherman's Syndrome is a condition in which there is formation of scar tissue (called 'adhesions' or 'synechia') inside the uterus, obliterating the endometrial cavity partially or completely and preventing the occurance of normal menstrual periods.

The normal anatomy of the uterus consists of two thick muscular walls (the anterior uterine wall and the posterior uterine wall) enclosing a cavity called the endometrial cavity. The tissue lining of this cavity is called the 'endometrium'.

The main function of the endometrium is to proliferate and change in structure during each menstrual cycle so that a fertilized ovum can implant in it, should pregnancy occur in that cycle. If pregnancy does not occur, the endometrium degenerates and sloughs off during the menstrual period.

Adhesions inside the uterus can damage the endometrium to a greater or lesser degree. It thus fails to develop in each menstrual cycle leading to secondary amenorrhea.

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Asherman's syndrome can occur in any women of any age who have undergone an intra-uterine procedure like an abortion, D&C or a childbirth. But it is most common after a D&C is performed on a recently pregnant uterus.

Asherman's Syndrome
Asherman's Syndrome

Grades of Asherman's Syndrome

Depending on the extent and thickness of the adhesions, Asherman's Syndrome can be graded into mild, moderate or severe.

  • Mild Asherman's Syndrome: In this grade, the adhesions are thin and flimsy and easily torn with a thin instrument like an uterine sound or a hysteroscope. The endometrial cavity may be partially or totally covered by adhesions, but the endometrium is not damaged to a great extent. Prognosis is quite good.

  • Moderate Asherman's Syndrome: The adhesions in this grade are thicker with strands of muscular tissue mixed with the fibrous tissue. The endometrial cavity may be partly or completely affected. The adhesions cannot be broken easily and may bleed during the procedure.

  • Severe Asherman's Syndrome: The adhesions are thick, and there is extensive damage of the endometrium. The uterine walls stick together, completely obliterating the endometrial cavity.

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    Causes of Asherman's Syndrome

    The basic cause of Asherman's syndrome is injury to the endometrium, causing formation of scar tissue between the two uterine walls.

  • Dilatation and Curettage (D&C): A D&C (Dilatation and Curettage) needs to be performed after an abortion or a miscarriage to ensure that the uterus is completely emptied of its contents. Too rough curettage can damage the endometrium and cause formation of adhesions.

  • After a delivery: If the placenta fails to be expelled spontaneously after a delivery and is retained (called 'retained placenta'), it may need to be removed manually. Infections with formation of scar tissue are more likely to occur in such a situation . Sometimes a D&C also becomes necessary with a resultant Asherman's syndrome.

  • Surgery: Surgery on the uterus to remove tumors like fibroids can also damage the endometrium.

  • Radiation: Radiotherapy inside or around the uterus as a part of cancer treatment can also cause damage and adhesion formation.

  • Infections: Infections like pelvic tuberculosis or even certain STDs can also cause Asherman's syndrome.

    Treatment of Asherman's Syndrome

    Treatment of Asherman's syndrome is very difficult. The main aims of treatment are:

  • Removal of the scars by non-heat generating procedures. Scissors should be used, rather than lasers or resectoscopes. This is to prevent further damage to the endometrium.

  • Hormones should be prescribed to encourage growth of the endometrium so that the damaged portions are covered by normal endometrium.

  • The two uterine walls should be held apart as far as possible during the healing process to prevent recurrance of adhesions. This is usually done by inserting an intrauterine device (IUCD) like Cu-T or Lippes loop immediately after the adhesions are removed.

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