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.

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.

    Pathophysiology of Asherman's Syndrome
    Pathophysiology of Asherman's Syndrome

  • Dilatation and Curettage (D&C): A D&C (Dilatation and Curettage) is the commonest cause of Asherman's syndrome. It needs to be performed after an abortion or a miscarriage to ensure that the uterus is completely emptied of its contents. The procedure consists of scraping the uterine endometrium. But if the scraping is too severe, it can damage the deep basal layer of the endometrium, causing the different parts of the endometrium to stick to each other or to the muscular wall of the uterus. 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.

  • Cesarean Section: A Cesarean section can also cause damage to the endometrium, either while delivery of the baby or while removing the placenta. Infection can also cause damage.

  • 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 like Chlamydia trachomatis can cause adhesions and scarring leading to Asherman's syndrome.

  • Hysteroscopic Surgery : A hysteroscopy may need to be done to identify any conditions inside the uterus. A small camera is inserted and the uterine cavity examined under direct vision. It may be followed by damage or an infection inside the uterus.

    The symptoms of Asherman's Syndrome can vary, depending on its severity. Mild Asherman's may not cause any symptoms at all. Some of the most common signs and symptoms include:

    • Heavy or light menstrual periods or complete absence of menstrual bleeding
    • Painful menstrual periods
    • Pain and/or cramping during intercourse
    • Chronic pelvic pain
    • Low back pain
    • Lower abdominal pain
    • Passing of white and/or clear discharge
    • Abnormal bleeding or spotting between menstrual periods
    • Infertility
    • Recurrent miscarriages.
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    Asherman's syndrome is not easy to diagnose by by physical signs and symptoms alone. A mild case may not have any symptoms. Diagnostic measures like ultrasounds are necessary for a accurate diagnosis.

    • Ultrasound - Ultrasound is one of the most commonly used diagnostic aid. A very thin endometrial lining in a patient with amenorrhea (loss of periods), or other menstrual irregularities may be suggestive of adhesive scarring inside the uterus. Some areas in the endometrium may be thin due to the scars and lack of growth of the endometrium .

    • Blood Tests - Blood tests may be need to be ordered to rule out infections, especially infections with Chlamydia or Tuberculosis.

    • Hysterosalpingography (HSG) - HSG is a procedure in which a radio-opaque dye is injected into the uterus by a special canula. The movement of the dye is tracked by a series of Xrays. Any defect in the endometrium or adhesions may show up as deficient space occupying spots .

    • Saline sonography - Saline sonography is similar to HSG except that it uses saline instead of dye for the diagnosis. Advantages of saline sonography compared with hysterosalpingography are that it does not involve radiation or a special diagnosis suite. It can be done in the office.

    • Hysteroscopy - A hysteroscopy is can usually confirm the diagnosis. A hysteroscope is a slender tube through which a camera can be inserted into the vagina and uterus to examine the inner cavity of the uterus under direct vision. Hysteroscopy is the gold standard for diagnosing, classifying and treating the disease. Diagnosis with hysteroscopy may be combined with treatment procedures like lysis of the scar tissue.

    Asherman's syndrome is treated using a combination of medicinal and surgical techniques. The main aims of treatment are (1) Removal of the scars and (2) Encourage growth of nomal endometrium.

    Treatment of Asherman's Syndrome
    Treatment of Asherman's Syndrome

  • Surgery - Hysteroscopic adhesiolysis is a common treatment used to treat Asherman's syndrome. It includes inserting a thin, flexible tube called a hysteroscope through the cervix in order to remove the scar tissue. Scars should be removed by non-heat generating procedures. Scissors should be used, rather than lasers or resectoscopes. This is to prevent further damage to the endometrium. In more severe cases, laparoscopy is used in addition to hysteroscopy as a protective measure against uterine perforation.

    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 or a balloon stent (Foley catheter or Cook stent) containing saline for up to 3 weeks immediately after the adhesions are removed.

  • Medical Treatment - Medical treatment usually follows surgical removal of the fibrous bands in the uterus. Hormonal therapy with synthetic or conjugated estrogen is usually prescribed following surgery to stimulate endometrial growth and ensure that the damaged portions are covered by normal endometrium. This can prevent the uterine walls from adhering again.

  • Treatment of Infections - Although Chlamydia and PID can sometimes cause Asherman's, the the only specific infection that causes Ashermans Syndrome is genital tuberculosis. Although antibiotics would not cause the scars to clear up or prevent secondary intrauterine infectious complications, antibiotics are mandatory when infection is the cause of adhesion formation.

  • Lifestyle Changes - Altering one's way of life may help lower the likelihood of developing new scars. Avoiding strenuous activities, lowering stress levels, and maintaining a nutritious diet can all help.

  • New treatment procedures - Experimental protocols to rebuild the endometrium by infusing stem cells derived from the patient's blood cells, fresh or freeze-dried amniotic tissue may be used in the future. These have not yet been tested widely and there is no data about their effectiveness. Adhesive gels containing synthetic hyaluronidase have been studied and show promise to some extent.

  • Restoration of Fertility - It is difficult to say whether removal of the adhesions will help restore fertility. The endometrium will need to be built up with prolonged hormonal treatment to allow for implantation of the embryo and help with pregnancy. Re-evaluation should be done one to two weeks after surgery for early identification of recurrent adhesions while still small and to allow resection before these adhesions worsen. Follow-up testing is necessary to ensure that scars have not reformed. Further surgery may be necessary to restore a normal uterine cavity.

    Asherman's syndrome can be prevented by avoiding surgery on the uterus as far as possible.

    • Medical alternatives to D&C for evacuation of retained placenta/products of conception, medicines like misoprostol, methotrexate and mifepristone should be used. This can help prevent a D and C. Studies show that this less invasive and cheaper method to be to be efficacious, safe and an acceptable alternative to surgical management for most women.

      Alternatively, D&C could be performed under ultrasound guidance rather than as a blind procedure . The surgeon would be able to stop scraping the lining once all residual tissue has been eliminated, avoiding an injury to the endometrium.

    • Infections Treatment of infections very early may help prevent adhesions

    • Miscarriages Miscarriages can be treated by a combination of Misoprostol to evacuate the uterus and antibiotics to prevent an infection.
    It is important for women to be aware of the symptoms of Asherman's Syndrome and seek medical advice if they experience any of them. Early diagnosis and treatment of Asherman's Syndrome can help to minimize the impact of the condition and restore a healthy reproductive life.

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