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Asherman's Syndrome

Asherman's Syndrome is a rare, acquired uterine disease that causes adhesions (scar tissue) to form in the uterus. The disease may be mild, with adhesions occurring in only a small portion of the uterus, or severe, when the adhesions are so extensive they cause the front and back walls of the uterus to stick to one another. The adhesions may be thick or thin, spotty or joined. The condition is named after Dr. Asherman, an Israeli gynecologist who first described the condition in the mid-20th century when he noted that some women who had surgical treatments around childbirth subsequently stopped having periods.

Asherman's can be caused by several different factors. It appears most often in women who have had a dilation and curettage (D&C) to remove a retained placenta after childbirth, to clear the uterus after miscarriage, or to abort a pregnancy. It appears to be particularly common if the D&C was performed after a miscarriage or termination of pregnancy that occurred between 12 and 20 weeks and in the postpartum period when the endometrium is extremely vascular and sensitive. A 1998 study in the Netherlands found 40 percent of women in the study who underwent a D&C developed Asherman's Syndrome, while other studies suggest that 1 in 100 postpartum D&Cs result in Asherman's. It is thought that "overly aggressive" D&Cs during which the doctor scrapes the uterine walls with too much force or with a sharp instrument increase the risk of developing Asherman's. However, it can also be caused by trauma to the interior of the uterus as a result of a cesarean section, uterine infection due to a sexually transmitted disease, and other types of uterine surgery such as myomectomy (to remove uterine fibroids).

Symptoms of Asherman's Syndrome include amenorrhea (absence of menstrual periods), pain and cramping around the time a menstrual period should occur, recurrent miscarriage, and infertility. Asherman's is believed to be under-diagnosed because it is undetectable by routine diagnostic procedures such as ultrasound.

The best way to diagnose Asherman's Syndrome is by using a diagnostic hysteroscopy or a hysterosalpingogram (HSG). In a diagnostic hysteroscopy, the doctor dilates the cervix and inserts a tiny scope that enables him or her to see inside the uterus. An HSG is performed by inserting a small catheter into the cervix and then injecting radioactive dye into the uterine cavity while performing an x-ray. However, in more severe cases, the scarring is so extensive that the cervix or uterus is blocked and the catheter cannot be inserted and the dye will not flow into the uterus. In these cases, the doctor will revert to a diagnostic hysteroscopy.

If you are diagnosed with Asherman's Syndrome, it is important you see a surgeon who specializes in treating this condition. The most common treatment is surgery to remove the adhesions. However, this is a very delicate and difficult procedure and an inexperienced doctor may actually aggravate the condition if it is not performed correctly. The doctor must cut deep enough into the endometrial lining to remove the root or source of the scarring, but not so deep as to damage the endometrium. Most doctors will perform a hysteroscopy using microscissors to remove the adhesions, and insert a uterine balloon that is left in the uterus for 7 to 10 days to prevent the walls from re-sticking. Other doctors may forego the uterine balloon and instead recommend repeated and frequent hysteroscopies during which any new adhesions are removed. Surgery is usually followed by a course of antibiotics and estrogen, followed by progesterone.

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