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Asherman's Syndrome

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Recently, several readers have requested information or had complications I suspect are related to "Asherman's syndrome." Two comments and my responses are included below...

Julia Mangan has left a new comment on your post "Request to My Readers...":

Thank you for all your work on the blog and answering our comments!
I would love for you to address Asherman's Syndrome at some point and the risks of D&C's.


So be it Julia! See my response to the reader below and the comments that follow addressing Asherman's syndrome.
Dr T

At Thu Jun 05, 09:33:00 AM 2008, Anonymous said…

I had a miscarriage at 11-12 weeks of pregnancy in Nov 2008 due to some unknown infection. I had slight spotting in the 5th and 6th week then again in 11th week… the spotting increased to bleeding and 2 days before the miscarriage I had fever, chills and vomiting…and had a very painful miscarriage and the doctor did a D&C.

Now I am trying again for the past 2 months. This month my period has been delayed by 5 days and I had spotting like its a beginning of period….However, I do not have any pregnancy symptom this time expect that my period is delayed…I am worried that the first miscarriage due to infection could have affected my fallopian tube although the doctor said in most cases it won’t…Why do I have spotting? Does it mean that my uterus not strong
enough? Could a doctor please reply to my question….

At Sat Jun 07, 08:21:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 5: If you have not had a normal period since the D&C, and are just spotting, I am concerned that you either are not yet ovulating normally, or that you might have developed "Asherman's syndrome." This is scarring of the lining of the uterus that can occur if you have a D&C that is preceded by infection inside the uterus. If you do not have a normal period within the next couple of months, you need to discuss this possibility with your doctor. If you develop Asherman's syndrome, it is very hard to get pregnant unless you get some help. Dr T

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J.G. Asherman described the syndrome that now bears his name in a 1948 publication in what was then known as the Journal of Obstetrics and Gynecology of the British Empire. The condition he termed “amenorrhea traumatica (atretica),” basically, the absence of menstrual bleeding following trauma (specifically, D&C – dilatation and curettage) to the inner lining of the uterus, was further defined in a subsequent paper in the same journal (1950;57:892-96). Earlier descriptions in case studies were discussed in the 1890’s by several physicians, including Heinrich Fritsch in 1894, and the condition can be found occasionally referenced as the Fritsch-Asherman syndrome.

So, what is Asherman’s syndrome; under what conditions does it come about; what problems does it cause; how is it diagnosed; and, what can be done about it? To help understand this condition, let’s first discuss the uterine anatomy. The innermost lining of the uterus is called the endometrium. It contains the tissues (blood vessels and glands) that proliferate in the early stages (estrogen-dependent) of the menstrual cycle and then becomes conditioned (decidualized) following ovulation (progesterone-dependent) to facilitate the implantation of the egg should it become fertilized on its journey down the fallopian tube. If fertilization does not occur (or the embryo does not implant), the upper portion of the endometrium (the functional layer) sheds and regresses with the bleeding that accompanies the menstrual period. Normally, when tissues are damaged and bleed, they tend to adhere to each other in the presence of blood clot and begin to form scar tissue. However, one very important characteristic of the innermost endometrial layer is that this does NOT usually occur – in other words, one key role of the endometrium must be to keep the inside of the uterus from sticking together and closing up!

In Asherman’s syndrome, on the other hand, that’s exactly what happens – the uterine cavity becomes obstructed by scar tissue (intrauterine synechiae) and if this is severe enough, there may not be sufficient endometrium remaining to cycle normally, resulting in very light periods (hypomenorrhea) or even the complete absence of periods (amenorrhea). There are several conditions that are together associated with more than 90% of all cases of Asherman’s syndrome (Schenker, et al., Fertility Sterility 1982;37:593-610): pregnancy, intrauterine infection, and trauma (usually by D&C) to the endometrium. This triad of conditions can lead to an intense inflammatory response and denuding of the endometrium into the deeper (basalis) layer, or into the stromal connective tissue, or the muscle (myometrium) of the uterus itself, which do not have the same regenerative capabilities as the innermost layer of the endometrium, nor the same capacity to prevent activation of pathways that can lead to the formation of scar tissue. Although Asherman’s syndrome probably complicates no more than about 1% of D&C's done electively and in the absence of infection, it has been estimated to occur in about 25% of these procedures that are done one to four weeks following pregnancy (Buttram, et al., In J Fertil 1977;22:98-103) and as many as 30% of missed spontaneous abortions with the length of time between fetal demise and the D&C itself being directly correlated with the risk of adhesion formation (Adoni, et al., Int J Fertil 1982;27:117-18).

Of the three conditions, the presence of infection perhaps contributes the most to the onset of adhesion formation. The result, in the most severe cases, is that the entire uterine cavity may be completely fused together. In the developing world, chronic endometritis from pelvic tuberculosis (Netter, et al., Am J Obstet Gynecol 1956;71:368-75) and schistosomiasis (Krolikowski, et al., Obstet Gynecol 1995;85:898-9) are major causes of intrauterine synechiae. Other uterine procedures, such as removal of fibroids (myomectomies) and even cesarean section have been associated with Asherman’s syndrome, but these are less common causes.

Other than light or absent periods, the primary complications related to Asherman’s syndrome are recurrent miscarriages and infertility. Patients at risk for or suspected of having Asherman’s syndrome, who still have pain occurring at the expected time of menstruation in the absence of significant or any menstrual flow, may have obstruction of the cervix by scar tissue and are then at risk for accumulating menstrual blood and tissues within the uterine cavity (hematometra) and also may develop endometriosis as a secondary consequence of this. In addition to the risk of miscarriage when pregnancy occurs, women with intrauterine adhesions are at risk for later pregnancy complications related to abnormalities of placentation, either small placentas with poor blood supply or a placenta accreta (placentation into the deeper basalis layer and the myometrium). These conditions increase risk for cervical incompetence, poor fetal growth (intrauterine growth restriction), fetal demise, preeclampsia, early delivery, cesarean section, uterine rupture, postpoartum hemorrhage, and peripartum hysterectomy.

In our next post on this subject, we will discuss the diagnosis, treatment, and prevention of Asherman’s syndrome….
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