Asherman Syndrome

In some cases, you may not experience symptoms. But common symptoms include:

• Infertility
• Miscarriages
• Menstrual irregularities, such as very light periods (hypomenorrhea) or the absence of periods (amenorrhea)
• Pelvic pain

Most women with Asherman syndrome develop it after having surgery that involves their uterus, such as a dilation, which removes part of the lining of the uterus to treat heavy periods or clear the lining of the uterus after an abortion or miscarriage. The buildup of scar tissue also can be related to an infection of the uterus following an abortion, miscarriage, or delivery.

Although uncommon, you could develop Asherman syndrome without having any of these common factors.

A hysteroscopy, a technique that doctors use to look directly in your uterus to identify scar tissue, is the most effective way to diagnose Asherman syndrome. Depending on the severity and type of scar tissue, it also may be possible to break up some of the scar tissue at the time of initial diagnosis.

Additional tests that may be performed include:

• Endometrial biopsy: Samples the lining of the uterus to determine if any normal endometrial tissue is present
• Hysterosalpingogram (HSG): An injection of dye into the uterine cavity that’s followed by an X-ray
• Sonohysterogram: An injection of fluid into the uterine cavity while looking with an ultrasound
• Transvaginal ultrasound: A pelvic ultrasound used to examine the uterine cavity

An HSG and sonohysterogram can suggest the presence of Asherman syndrome, but they don’t provide doctors with the level of visualization that hysteroscopies do. Transvaginal ultrasounds, meanwhile, can evaluate and measure the thickness of the endometrial lining.

We use guidelines from the American Society for Reproductive Medicine to classify the three different stages of Asherman syndrome, which include:

• Stage I (mild):A few filmy bands of scar tissue in a woman with normal periods
• Stage II (moderate):Thicker adhesions that are still covered by the endometrium with partial blockage of the endometrial cavity, and irregular periods
• Stage III (severe):Complete obliteration and blockage of the endometrial cavity and no bleeding

If you have Asherman syndrome, but you don’t have any symptoms and aren’t interested in having children, there is no medical reason why your scar tissue needs to be treated. If you do want or need treatment, however, treating Asherman syndrome involves two primary steps.

Step One: Removing Scar Tissue

The first step of treatment is breaking up scar tissue, opening the uterine cavity, and identifying the tubal ostia (the openings of the fallopian tubes into the uterus).

If the scar tissue is thin and filmy, it can be broken up bluntly using the hysteroscope. If the adhesions are thick and dense, your surgeon will use scissors to cut the scar tissue. The goal of the surgery is to completely open up the uterine cavity and be able to identify both tubal ostia. We sometimes use ultrasound to help guide the break down of adhesions.

Your doctor will perform your surgery in the office or operating room, depending on your circumstances and the extent of your adhesions. Most women go home the same day of surgery, have quick recoveries, and need minimal pain medication after surgery.

Step Two: Preventing Scar Tissue from Coming Back

A challenge with Asherman syndrome is keeping scar tissue away once it’s removed. While several techniques exist to prevent scar tissue from coming back, none have been shown to work better than another. These techniques include:

• Oral estrogen: You’ll receive a course of estrogen (typically for 30 days) after you have scar tissue removed to promote growth of normal uterine lining and help prevent scar tissue from returning
• Repeated hysteroscopies: Your doctor will perform additional hysteroscopies seven to 14 days after the initial one until there are no signs of scar tissue coming back
• Placement of an intrauterine balloon:Your doctor will place an inflated balloon or intrauterine device (IUD) inside the uterine cavity after scar tissue is removed to help prevent it from growing back
• Transvaginal ultrasound: Your doctor may use ultrasound to evaluate and measure the thickness of the endometrial lining to help indicate how much healthy endometrium there i
• Endometrial biopsy:Your doctor may sample the lining of the uterus to determine whether there is any normal endometrium in the uterus