You are not alone
Welcome. Here you will find reliable information about Asherman’s Syndrome and the understanding and hope you need to make your way through diagnosis and treatment.
We promote Asherman’s Syndrome prevention, diagnosis and effective treatment by informing women and increasing awareness in the medical community.
About Asherman's Syndrome
Background: A normal uterus resembles a deflated balloon, with the front and back walls resting against each other. The pocket is lined with tissue called endometrium. During menstruation this endometrial lining is shed, and then built up again in the following month. When a woman becomes pregnant, the embryo implants in the endometrium. In the case of Asherman’s syndrome, physical injury (from uterine surgery) or infection can damage the endometrial lining and cause scar tissue (adhesions) to form.
Asherman’s syndrome is the medical condition of having scar tissue inside the uterus and/or the cervix. Asherman’s syndrome almost always develops following uterine surgery (i.e. D&C, fibroid removal, etc.) or infection. With proper diagnosis and skilled treatment, Asherman’s syndrome frequently can be surgically corrected.
In many cases, Asherman’s syndrome scars form bands (adhesions) that cause the front and back walls of the uterus to get stuck together. In milder cases, adhesions only occur in a small portion of the uterus or cervix, in more severe cases, adhesions cover a large area of the uterus. Adhesions can be thin and stringy (easier to remove) or the adhesions can form thick bands.
Asherman’s syndrome adhesions may prevent an embryo from implanting, restrict the growth of an early fetus, and can result in miscarriages or infertility.
If you have Asherman’s syndrome, you can experience a variety of symptoms, including:
- Having very light periods (hypomenorrhea):
- Not having a period (amenorrhea). This can be caused by scars covering the entire uterus
- Not having a period and feeling pain at the time you would normally expect your period: This pain may indicate that menstruation is occurring but the blood cannot exit the uterus because the cervix and / or lower uterus is blocked by adhesions.
- Infertility or recurrent miscarriages
In some cases, you may not experience any symptoms. You may also still experience normal periods.
Direct visualization of the uterus via Hysteroscopy is the most reliable method for Asherman’s syndrome diagnosis. A Hysteroscope is a thin telescope that is placed into the uterus to identify the scars. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).
There are at least seven grading systems to describe Asherman’s syndrome severity in patients, but generally, the extent of the adhesions and type of adhesions, define whether the case is mild, moderate, or severe. In milder cases, adhesions only occur in a small portion of the uterus or cervix, in more severe cases, adhesions cover a large area of the uterus. Adhesions can be thin and stringy (easier to remove) or the adhesions can form thick bands.
There is a type of Asherman’s syndrome called ‘Unstuck Asherman’s’ or endometrial sclerosis, that is more difficult to treat. The scars in ‘unstuck Asherman’s’ do not cause the uterine walls to stick together. In ‘Unstuck Asherman’s’, scars form over the deeper, basalis layer of the endometrium. This deeper layer is responsible for regenerating the endometrial lining during the menstrual cycle. Although curettage can cause this condition, it is more likely after uterine surgery, such as myomectomy. ‘Unstuck Asherman’s’ scars may co-exist with adhesions.
Asherman’s syndrome symptoms are found in a few other common conditions. Your doctor may check for these other potential causes of menstrual dysfunction and/or infertility:
- Hormonal irregularities: (i.e. Under or over active thyroid, sex hormone imbalance, pituitary tumour or damage): A typical hormonal panel that your doctor may run could include; TSH, Prolactin, Estrogen, Progesterone, LH, FSH, AMH.
- Polycystic ovarian syndrome (PCOS): A mid-cycle ultrasound may be used to check for polycystic ovaries.
- Menopause or premature menopause: If menopause is suspected, your doctor will check your FSH (Follicle Stimulating Hormone) level.
Operative Hysteroscopy:
Asherman’s syndrome can often be cured with treatment. Most often, a hysteroscopic surgery is performed. A doctor will insert a hysteroscope that contains very thin scissors or a laser into your uterus to cut the adhesions (scars) on your uterine wall and / or cervix. This is the most important phase of your treatment. Removing scars without creating more scars or worsening the condition is not easy. It is important to choose a surgeon with experience treating Asherman’s syndrome.
Post-surgical treatment:
After your surgery you may have a balloon catheter inserted into your uterus to keep your uterine walls from adhering together during the healing process; if used, the balloon will usually stay inside for 5-14 days. You will also take an antibiotic to prevent infection.
Once the balloon is removed you may be prescribed a regimen of estrogen and/or progesterone. The dose and length of this regimen will vary depending on your doctor.
Follow-up
2-3 months after your surgery you may have an hysterosalpingography, sonohysterogram or diagnostic hysteroscopy to view the inside of your uterus and your fallopian tubes for remaining scar tissue.
Subsequent surgery may be necessary.
*Women who are not experiencing symptoms (pain, cramping), or trying to get pregnant, may not require treatment at all.
Is Asherman's syndrome rare?
At the International Asherman’s Association, we have supported thousands of women with Asherman’s syndrome. It is our firm belief, supported by medical research, that Asherman’s syndrome is a common, post-surgical cause of infertility and miscarriage.
Type of Prior Surgery | Frequency of Intrauterine scarring |
Caesarean section | 2.8% |
Early D & C for miscarriage | 6.4% |
Delayed D & C for miscarriage | 30.9% |
Multiple D & Cs for repeated miscarriages | 48.0% |
D & C performed any time after delivery | 3.7% |
D & C performed 2-4 weeks after delivery | 23.4% |
Removal of multiple fibroids on the inside of the uterus | 45.5% |
We believe that there are 3 major factors that contribute to Asherman’s being underdiagnosed:
- Asherman’s Syndrome is not usually detectable by routine examinations or diagnostic procedures such as an ultrasound scan. If a doctor is not specifically looking for Asherman’s syndrome via hysteroscopy, s/he probably won’t discover it.
- Asherman’s Syndrome is not always associated with symptoms. If a woman has no symptoms or if her symptoms don’t bother her, i.e., lighter periods, she (and her doctor) may never know that she has intra-uterine adhesions.
- Unfairly blaming doctors: For a long time, doctors were taught that Asherman’s syndrome was rare and the result of an ‘overly aggressive D&C’. When doctors didn’t believe they were overly aggressive, why would they perform a hysteroscopy to look for a ‘rare’ complication? So, Asherman’s syndrome was rarely diagnosed and doctors continued to believe that it is rare and so on, and so on.