Mr Adrian Lower, expert consultant gynaecologist and surgeon, answers questions surrounding Asherman's syndrome, a disease affecting the endometrium (part of the inner layer of the uterus). It is characterised by a decrease in duration of bleeding and flow in periods, or even a complete lack altogether.
What is Asherman's syndrome?
Asherman's syndrome is a condition in which adhesions inside the uterus lead to either a complete cessation of periods or much lighter periods than what you might have had previously. It’s often associated with surgery and infection inside the uterus sometimes at the time of the D&C (dilation and currettage) or a miscarriage, or after delivery of a baby. There is a 25% risk of developing Asherman's syndrome following a D&C performed 2-4 weeks after delivery, and 30.9% risk of developing Asherman's syndrome from D&C following a miscarriage.
What are the symptoms of Asherman's syndrome?
The symptoms of Asherman's syndrome are either a complete absence of periods or a reduction of your periods often associated and following childbirth or surgery to the uterus.
What are the causes of Asherman's syndrome?
Asherman's syndrome is caused by trauma to the endometrium, which normally means surgery of some description, for example either a D&C or a termination of pregnancy. It is usually made worse when there’s some infection present. The tissue is very soft after pregnancy, so even gentle scraping inside the uterus can scrape away the whole of the endometrium which means that adhesions or scarring form inside the uterus which will stick the front of the uterus to the back part of the uterus.
How can Asherman's syndrome be diagnosed?
The first thing to do is to be sure you’ve got an accurate diagnosis of Asherman's syndrome. This can be done by ultrasound scan so you can see whether the endometrium is thin or not, and sometimes you can actually see adhesions or loss of endometrium present in the uterus.
How is Asherman's syndrome treated?
Treatment is surgical. We then do a hysteroscopy which is where a small telescope is introduced through the cervix or the neck of the womb into the cavity of the womb. What’s really important is that we’re absolutely certain that that hysteroscope is in the true cavity of the uterus. When the cavity is obliterated, it’s very easy for the scope to slide either behind or in front of the uterus and when that happens, we can cause more damage than we do good and create a false passage or try to develop a false cavity in front of where the endometrium really ought to be. Procedures under ultrasound and x-ray control allow us to be absolutely certain that we know where the hysteroscope is and accurately locate what’s left of the endometrium to try to effect as good a repair as possible.
Once the surgery is completed, we then need to use either a stent or an intrauterine contraceptive device to hold the wall of the uterus apart so that the adhesions won’t reform. The other very important aspect to treatment of Asherman’s syndrome is to ensure that we give high dose estrogen treatment immediately after surgery to make the endometrium grow as thick as possible as quickly as possible so that new adhesions won’t form at the site at which we divided the old ones.