Asherman syndrome is a rare gynecologic disorder. In the worst cases, it can lead to infertility.
What is Asherman syndrome?
Asherman syndrome, also called Fritsch-Asherman syndrome or Fritsch syndrome, is a gynecologic condition in which the uterus is closed by adhesions, usually as a result of surgical procedures. In 1894, the German gynecologist Dr. Heinrich Fritsch described intrauterine adhesions for the first time and warned of the consequences of too intensive scratching during scrapings after miscarriages and in the puerperium. In 1948, the Czech-Israeli gynecologist Joseph G. Asherman described these adhesions as “post-traumatic intrauterine adhesions”. The clinical picture was named after him. Depending on the extent of the adhesions, four stages are distinguished.
Causes
When considering the medical history of affected women, scrapings are almost always found in the history. Women who have had scrapings during pregnancy or in the uterus that has not yet recovered after delivery are at particular risk. Schenker and Margalioth presented composite statistics in 1982 documenting that 66.7% of cases of intrauterine adhesions were due to curettage (scraping) after miscarriage, 21.5% were due to curettage after childbirth, and 2% were due to cesarean section. In 1990, Chapman and Chapman, who treated women with Asherman syndrome in several countries, recognized an association between adhesions and the use of a sharp rather than blunt curette. The risk increases with the number of additional curettes.
Symptoms, complaints, and signs
One common symptom is an absence of menstrual bleeding (amenorrhea) or menstrual bleeding that lasts only a short time (hypomenorrhea). Secondary amenorrhea may also occur after a normal cycle. If adhesions are present in the uterus and fallopian tubes, a woman may have difficulty getting pregnant. In many cases of infertility, adhesions are present that prevent pregnancy. Sometimes pregnancy occurs despite adhesions, and the adhesions can cause the fertilized egg not to implant properly, or result in miscarriage, premature birth, or problems in the postpartum period. That a woman becomes pregnant despite adhesions may be because the uterus and/or fallopian tubes are not completely obstructed by adhesions and there is sufficient intact endometrium. Often the adhesions cause pain, especially in amenorrhea, when the uterine lining built up during the cycle cannot be shed by menstruation because of uterine obstruction.
Diagnosis and course
Diagnosis of Asherman syndrome is difficult, especially because this condition is very rare. On the other hand, it is not known how high the number of unreported cases really is in view of misdiagnoses. It is important to take a careful history. In a typical Asherman syndrome, there have been abortions in the past and/or surgical interventions on the uterus, for example by cesarean section. If a woman does not become pregnant and suffers from secondary amenorrhea or hypomenorrhea, she should be evaluated for Asherman syndrome. After taking a careful history, an ultrasound examination can be performed, but adhesions are difficult to detect on ultrasound. In patients at risk of adhesions, saline hysterosonography (ultrasound examination with a saline solution) can be done to see if there are any strictures or occlusions. To examine the uterus more closely, a hysteroscopy (endoscopy of the uterus) is performed. Thanks to technical advances, such procedures can now be performed on an outpatient basis under local anesthesia in 98% of cases. Video hysteroscopy, which allows another examiner to assess the case, reduces the risk of misinterpretation. Hysteroscopy is particularly suitable because in the case of adhesions, the procedure can be extended to loosening the adhesions at any time. Hysterolsalpinography (X-ray examination of the uterus and fallopian tubes), in which the uterus and fallopian tubes are visualized with the help of a contrast medium, is often performed as part of fertility treatment.
Complications
Various complications occur with Asherman syndrome, and in the worst cases, complete sterility of the patient may occur. In most cases, Asherman syndrome causes women to miss their periods completely or to have very light bleeding. Usually, this is a sign of pregnancy for many women. However, women affected by Asherman syndrome are in many cases infertile and the body cannot sustain a pregnancy. In this case, there are strong psychological complaints and depression. Self-esteem is also greatly reduced in this case. In addition to the patient himself, the partner can also be affected by the psychological complaints. Asherman’s syndrome causes pain in many cases. If the woman becomes pregnant despite the adhesions, the pregnancy usually ends in miscarriage. The miscarriage can lead to severe psychological complications that need to be treated by a psychologist. The treatment is carried out exclusively by surgical intervention. The intervention is very complicated for doctors and does not lead to success in every case. In case of unsuccessful surgery, adhesions may continue to form. In case of success, the woman may become pregnant. However, pregnancies are associated with risks.
When should you see a doctor?
Asherman syndrome does not necessarily need to be evaluated by a doctor. A medical diagnosis is recommended if there are persistent symptoms during menstruation (absence or delay of periods, among others). If the above symptoms occur after a curettage or a disease of the uterus, it is probably Asherman’s syndrome. However, a visit to the gynecologist is not always necessary. However, women who wish to have children should have such abnormalities clarified, as untreated Asherman’s syndrome can lead to infertility, miscarriage and premature birth, and problems in the postpartum period. So, depending on the severity of the symptoms, Asherman syndrome does not necessarily require medical treatment. If the adhesions cause psychological or physical discomfort or jeopardize a specific desire to have a child, clarification of the condition is necessary. If diagnosed appropriately, the adhesions can be loosened and and removed. The right contact person is always the gynecologist. If it is Asherman syndrome, the gynecologist will refer the treatment to a specialist.
Treatment and therapy
Because Asherman syndrome is little known even among gynecologists, there are few specialists in its treatment. For successful therapy, the adhesions must be loosened and removed. A great deal of experience is required for surgeons to adequately reconstruct the uterine cavity. If the procedure is not done correctly, the condition will worsen. Removal of adhesions is done endoscopically during hysteroscopy. If the patient is lucky, the uterus still contains enough healthy mucosa to spread after the procedure and prevent new adhesions. In this case, she might even become pregnant. However, all further pregnancies are considered high-risk pregnancies. If the uterine wall has been so severely damaged by a curettage that no intact remnants remain, new adhesions will form again. The woman is then infertile. Even if the procedure is successful, careful follow-up is necessary.
Outlook and prognosis
The prognosis of Asherman syndrome is unfavorable. The adhesions can be resolved only with great effort and gynecologic experience. Even specialists are unable to provide a complete cure for the syndrome in many cases. Without medical care there is no change in the conditions. The tissue cannot regress to its natural shape without an external influence. In severe cases, sexually mature women are threatened with a diagnosis of sterility. With treatment, the prognosis is somewhat better, but still not optimal. Again, in severe cases of adhesions, there is no chance of cure and the woman is also threatened with infertility. This often leads to psychological sequelae and emotional stress. Currently, the only therapeutic way to cure Asherman’s syndrome is surgical intervention.It can take several hours depending on the severity of the adhesions. In some cases, only gradual separation of the intergrown tissue areas is possible. If the uterus has sufficient mucosa, it can spread after the procedure and lead to a positive prognosis. Pregnancy would then be possible, but is associated with risks. In the case of severe damage to the tissue, there is a relapse and recurrence of adhesions despite surgery afterwards.
Prevention
To prevent Asherman syndrome, it is important for gynecologists to weigh the risks of a curettage with their patients and discuss possible alternatives with them. If it is still necessary, it is important to perform it carefully. If menstruation does not resume after a curettage, Asherman syndrome should be investigated. If possible, scraping should not be performed after a postpartum pregnancy because the endometrium is still sensitive.
Follow-up care
Because Asherman syndrome is a hereditary condition, it cannot be fully treated. As a result, the options for aftercare are also very limited, so the affected person is primarily dependent on medical treatment. If the patient also has a desire to have children, genetic counseling may be useful. In this way, the inheritance of Asherman syndrome can possibly be avoided. In most cases, the syndrome itself is treated by surgical intervention. The patient should definitely rest and refrain from physical activity after such a procedure. Physical exertion and other stressful situations should be avoided. Stress should also be avoided. The procedure may not always result in a complete recovery. In some cases, a second treatment is also necessary. Furthermore, the contact of the affected person with other Asherman syndrome patients can have a positive effect on the course of the disease. This can lead to an exchange of information, which can make everyday life easier. Since pregnancies after successful surgery are always high-risk pregnancies, additional examinations are highly advisable to avoid complications. The life expectancy of affected individuals is usually not reduced by Asherman syndrome.
Here’s what you can do yourself
Asherman syndrome is a very rare condition that is often overlooked during a routine physical exam. Women who suffer from cramps in the abdomen, bleeding and other non-specific symptoms should therefore consult a specialist immediately. The actual symptoms can be alleviated by various self-help measures. First of all, heat applications are a good choice. Spelt or cherry stone pillows relieve abdominal pain and have an overall relaxing effect. A warm full bath with lemon balm or chamomile as a bath additive also reduces the typical symptoms. In addition, rest and bed rest are recommended. In consultation with the doctor, the pill can be taken, because the preparation regulates the hormone balance and thus contributes to the relief of the typical symptoms. Affected women should also drink plenty of water and eat a healthy diet. Sporting activity should be avoided at first. After surgery, discomfort can be alleviated by gymnastic exercises or yoga. If pain persists after removal of the adhesions, the doctor must be consulted again. Asherman’s syndrome is not life-threatening, but medical steps must still be taken, as well as self-help measures, otherwise the symptoms will become more severe over time.
