Asherman\'s Syndrome ( intrauterine adhesions)

Asherman's Syndrome or intrauterine adhesions (scars or synechiae) occurs when bands of fibrous scar tissue form inside the uterus. Most patients with Asherman's have scanty or absent periods (amenorrhea). The diagnosis is often missed because it cannot be made on routine ultrasound scans.

What is Asherman's Syndrome?

Asherman's Syndrome, or intrauterine adhesions ( scars or synechiae) occurs when adhesions (bands of fibrous scar tissue) form inside the uterus. The extent of the adhesions defines whether the case is mild, moderate or severe. A Grades system is used to classify the severity of the disease.

Symptoms

Most patients with Asherman's have scanty or absent periods (amenorrhea) . The diagnosis is often missed because it cannot be made on routine ultrasound scans.

Causes

Asherman's syndrome occurs when trauma to the uterine lining ( the endometrium) causes the damaged areas to fuse together. Most commonly, intrauterine adhesions occur after a D &C ( dilatation and curettage) that was performed because of a missed or incomplete miscarriage. It may also occur after a D &C done to treat a retained placenta; or after an elective abortion. Pregnancy-related D &Cs have been shown to account for 90% of Asherman's cases . Adhesions may also occur following other pelvic surgeries such as cesarean section, myomectomy or as a result of infections such as genital tuberculosis.

There is a variant of Asherman's Syndrome that is more difficult to treat. This is the condition of a "thin endometrium" or endometrial sclerosis. Here the endometrium has been denuded and cannot grow properly.

Diagnosis

The doctor can suspect this diagnosis if your periods stop , or become very scanty. Usually, this happens after a D &C or other surgery.

Since there are other reasons for missing a period, the doctor will need to confirm the diagnosis. This can be done by treating you with hormones, to see if your uterine lining is capable of responding properly to them.

We use the following protocol.

Tab Lynoral ( ethinyl estradiol) , 0.05 mg , 1 tab daily with dinner, from Day 1 - Day 25.

Vaginal ultrasound scan on Day 12 to check your endometrial thickness and texture.

Then take Tab Deviry ( medroxyprogesterone acetate) , 10 mg, twice a day from Day 16-25.

If the uterine lining is thin; and you do not get a period after taking the Deviry, the diagnosis is confirmed

The diagnosis is confirmed by doing a hysteroscopy . Other methods include a HSG in which the adhesions are visualised as filling defects within the uterine cavity.

Prevention

Ideally, prevention is the best solution. Missed abortions are best treated with medicines , using Mifepristone and Misoprostol, thus avoiding surgical intervention

Treatment

Asherman's must be treated by a very experienced surgeon via hysteroscopy . Adhesions have a tendency to reform , especially in more severe cases. Re-scarring after surgery can be prevented with the help of estrogen supplementation to stimulate uterine healing; and by placing a balloon or IUD to prevent the walls from sticking to each other during the post-operative healing phase.

You can read more about Asherman's syndrome here !