Asherman’s Syndrome

Asherman’s Syndrome refers to scar tissue inside the uterus that occurs following a pregnancy, pelvic infection or surgical procedure. Adhesions (scar tissue) inside the uterus cause the uterine walls to stick together leading to decreased or no menstrual flow, sometimes in association with pain. The main concern with Asherman’s syndrome is that it can lead to problems becoming pregnant or pelvic pain due to the intrauterine scarring.

How does Asherman’s syndrome occur?

There are a variety of causes of Asherman’s syndrome with the most common causes related to events of a pregnancy although it may occur at other times. Asherman’s may develop after:

Surgery following from a miscarriage or incomplete delivery of the placenta after birth.
Infection of the lining of the uterus, called endometritis, near the time of a pregnancy or unrelated to any pregnancy.
Other surgery in the uterus including a curette or removal of polyps or fibroids from the uterus (although this is rare).

It is uncertain why some women develop Asherman’s syndrome following relatively simple procedures or infection, whereas other women do not suffer the same problems.

What are the symptoms of Asherman’s syndrome?

Reduced or absent periods is the most common symptom. Pelvic pain may also occur due to areas of trapped menstrual fluid being squeezed by the surrounding muscular walls of the uterus. If the cervix is completely blocked by scar tissue then the fluid that builds up behind the obstruction cannot flow out and the pressure can cause pain that is sometimes so great that it requires admission to hospital and strong pain killers.

It is presumed that adhesions can affect fertility, however the degree that these adhesions cause difficulties in becoming pregnant is unknown, since there may be women who have adhesions and become pregnant easily.

How is Asherman’s Syndrome diagnosed?

Like many other conditions in gynaecology, your personal history of any possible events that could lead to Asherman’s is very important. Dr Budden will ask you about all your pregnancies, and abdominal or pelvic surgery you have undergone, and any pelvic infections you may have suffered from. The diagnosis of Asherman’s can then be made in one of two ways:

X-ray or ultrasound – In these tests, a small tube is placed through the cervix into the uterus and a fluid is pushed into the uterine cavity. The dye will flow all around the cavity, with the scar tissue causing an abnormal shape or shadow seen on the X-ray or ultrasound.
Hysteroscopy – This is performed under general anaesthesia and allows for direct vision of the inside of the uterus. If adhesions are identified, they may be able to be treated at the same time.

How is Asherman’s Syndrome treated?

The best way to treat Asherman’s Syndrome is by a surgical procedure to remove scar tissue from the uterine cavity and restore it to normal function. Dr Budden will admit you to hospital and perform the procedure under general anaesthetic. A thin hysteroscope is used to look through the cervix and identify the areas of scar tissue. In difficult cases, Dr Budden may need to pass a small needle through the scar tissue and then inject a special dye while using an X-ray machine to help find the normal passage. The same dye and X-ray machine can also be used to check that the tubes are open and that it would be possible for a spontaneous pregnancy to occur after treatment.

After the procedure you will be prescribed oestrogen to be taken for three weeks following your treatment to ensure that your body has every opportunity to repair the endometrium (lining of the uterus) naturally and reduce the risk of the scar tissue reforming. A repeat hysteroscopy is then performed 4, 8 or 12 weeks later to check whether the uterine cavity and cervix are normal and would allow both normal menstruation and the possibility of pregnancy. The average number of surgeries required to reconstruct the cavity is 2, though this may vary from 1 – 6.