Asherman syndrome is a rare gynecological disease. In the worst case, it can lead to sterility.
What is Asherman Syndrome?
According to DigoPaul, Asherman syndrome, also known as Fritsch-Asherman syndrome or Fritsch syndrome, is a gynecological disease in which the uterus is closed by adhesions, usually as a result of surgical interventions. In 1894, the German gynecologist Dr. Heinrich Fritsch first developed intrauterine adhesions and warned of the consequences of intensive scratching when scraping 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. Four stages are distinguished depending on the extent of the adhesions.
If you look at the anamnesis of affected women, you will almost always find scraps in the history. Women who are scraped during pregnancy or in the uterus that has not yet regressed after giving birth are particularly at risk.
Schenker and Margalioth presented collective statistics in 1982 in which they documented that 66.7% of the cases of intrauterine adhesions are due to curettages (scrapes) after miscarriages, 21.5% to curettages after childbirth and 2% after a caesarean section.
In 1990, Chapman and Chapman, who were treating women with Asherman syndrome in different countries, discovered a link between adhesions and the use of a sharp rather than a blunt curette. The risk increases with the number of further scrapes.
Symptoms, ailments & signs
A common symptom is a lack of menstrual bleeding (amenorrhea) or a short menstrual period (hypomenorrhea). Secondary amenorrhea can occur even after a normal cycle.
If there are adhesions in the uterus and fallopian tubes, a woman may have difficulty getting pregnant. In many cases of infertility, there are adhesions that prevent pregnancy.
Sometimes a pregnancy occurs despite adhesions and the adhesions can prevent the fertilized egg from implanting properly, or lead to miscarriages, premature births or problems in the postpartum phase. The fact that a woman becomes pregnant despite adhesions may be due to the fact that the uterus and / or fallopian tubes are not completely obstructed by adhesions and that there is sufficient intact uterine lining.
The adhesions often cause pain, especially in the case of amenorrhea, when the uterine lining that has built up during the menstrual cycle cannot be shed by the menstrual period because of a blockage of the uterus.
Diagnosis & course
Diagnosing Asherman syndrome is difficult, especially because the condition is very rare. On the other hand, one does not know how high the number of unreported cases really is in the face of misdiagnosis. A careful medical history is important.
In a typical Asherman syndrome, there have been scrapes in the past and / or surgical interventions on the uterus, for example by a caesarean section. If a woman does not become pregnant and has secondary amenorrhea or hypomenorrhea, evaluation for Asherman syndrome should be made.
After taking a careful history, an ultrasound scan may be done, but adhesions are difficult to see on ultrasound. For patients at risk of adhesions, saline hysterosonography (ultrasound examination with a saline solution) can be carried out in order to be able to see whether there are constrictions or obstructions. In order to be able to examine the uterus more closely, a hysteroscopy (mirroring of the uterus) is performed.
Thanks to technical advances, such interventions can already be carried out on an outpatient basis under local anesthesia in 98% of cases. A video hysteroscopy, which another examiner can use to assess the case, reduces the risk of misinterpretations. Hysteroscopy is particularly suitable because, in the case of adhesions, the intervention can be extended to loosening the adhesions at any time.
As part of fertility treatment, hysterol alpinography (X-ray examination of the uterus and fallopian tubes) is often performed, in which the uterus and fallopian tubes are shown with the help of a contrast medium.
In Asherman’s syndrome there are various complications, and in the worst case, complete sterility of the patient can occur. In most cases, Asherman’s syndrome leads to the fact that women have no menstrual period at all or only very weak bleeding occurs. As a rule, this is a sign of pregnancy for many women.
However, in many cases women affected by Asherman syndrome are sterile and the body cannot sustain pregnancy. This leads to strong psychological complaints and depression. Self-esteem is also greatly reduced. In addition to the patient himself, the partner can also be affected by the psychological complaints.
Asherman syndrome causes pain in many cases. If the woman becomes pregnant despite the adhesions, the pregnancy usually ends in a miscarriage. The miscarriage can lead to severe psychological complications that require treatment by a psychologist.
The treatment is carried out exclusively through an operative procedure. The procedure is very complicated for doctors and does not always lead to success. If the procedure is unsuccessful, adhesions can continue to develop. If successful, the woman may become pregnant. However, pregnancies are fraught with risks.
When should you go to the doctor?
Asherman syndrome does not necessarily need to be clarified by a doctor. A medical diagnosis is recommended if there are persistent symptoms during the menstrual period (missed or delayed periods, etc.). If these symptoms occur after scraping or uterine disease, it is likely Asherman’s syndrome.
However, a visit to the gynecologist is not always necessary. However, women who want to have children should have any abnormalities clarified, since untreated Asherman syndrome can lead to infertility, miscarriages and premature births and problems in the postpartum phase.
Depending on the severity of the symptoms, Asherman syndrome does not necessarily have to be treated by a doctor. If the adhesions cause psychological or physical complaints or endanger a specific desire to have children, clarification of the disease is necessary. With an appropriate diagnosis, the adhesions can be loosened and removed. The right contact person is always the gynecologist. If it is Asherman’s syndrome, the gynecologist will hand over treatment to a specialist.
Treatment & Therapy
As Asherman’s syndrome is little known even among gynecologists, there are few specialists available to treat it. For a successful therapy, the adhesions must be loosened and removed. A lot of experience is necessary for the surgeon in order to be able to reconstruct the uterine cavity appropriately. If the procedure is not done correctly, the condition will worsen.
The removal of the adhesions is carried out endoscopically as part of a hysteroscopy. If the patient is lucky, the uterus still contains enough healthy mucous membrane, which can expand after the procedure and prevent new adhesions. In that case, she could even get pregnant. However, all other pregnancies are considered high-risk pregnancies.
If the uterine wall has been so badly injured by scraping that no intact residues remain, new adhesions will form again. The woman is then sterile. Careful follow-up treatment is necessary even if the procedure is successful.
Outlook & forecast
The prognosis for Asherman syndrome is poor. The adhesions can only be loosened with great effort and with a lot of gynecological experience. In many cases, even specialists are unable to guarantee a complete cure of the syndrome. Without medical care there is no change in the circumstances. The tissue cannot develop back into its natural shape without external influence.
In severe cases, sexually mature women are at risk of being diagnosed with sterility. With one treatment, the prognosis is slightly better, but not optimal. Here, too, there are no chances of recovery from severe adhesions and the woman is also at risk of sterility. This often leads to psychological complications and emotional stress.
The currently only treatment for curing Asherman’s syndrome is surgery. It can take several hours to complete, depending on the severity of the adhesions. In some cases, only a gradual separation of the tissue areas that are growing together is possible.
If the uterus has sufficient mucous membrane, this can spread after the procedure and lead to a positive prognosis. Pregnancy would then be possible, but it is associated with risks. If the tissue is severely damaged, the adhesions will relapse and come back again, despite an operation.
In order to prevent Asherman syndrome, it is important that gynecologists weigh up the risks of scraping with their patients and discuss possible alternatives with them. However, if it is necessary, it is important to do it carefully.
If menstrual periods do not resume after scraping, they should be checked for Asherman’s syndrome. After a pregnancy in the puerperium, there should be no scraping, if possible, because the uterine lining is still sensitive.
Because Asherman syndrome is an inherited condition, it cannot be fully treated. The options for follow-up care are also very limited, so that the person affected is primarily dependent on medical treatment. If the patient also wants to have children, genetic counseling is useful.
This may prevent Asherman syndrome from being inherited. In most cases, the syndrome is treated by surgery itself. After such an operation, the patient should definitely rest and not exercise. You should refrain from physical exertion and other stressful situations. Stress should also be avoided.
A complete cure cannot always be achieved through the procedure. In some cases a second treatment is necessary. Furthermore, the contact of those affected with other patients with Asherman syndrome can also 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 a successful procedure are always high-risk pregnancies, additional examinations are very advisable in order to avoid complications. Asherman syndrome does not usually reduce the life expectancy of those affected.
You can do that yourself
Asherman syndrome is a very rare condition that is often overlooked during a routine check-up. Women who suffer from cramps in the abdomen, bleeding and other non-specific symptoms should therefore consult a specialist immediately. The actual complaints can be alleviated through various self-help measures.
First of all, there are applications of heat. Spelled or cherry stone pillows alleviate 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 apply.
In consultation with the doctor, the pill can be taken, because the preparation regulates the hormonal balance and thus helps to alleviate the typical symptoms. Affected women should also drink plenty of water and eat healthily. Exercise should initially be avoided.
After a procedure, the symptoms can be relieved with gymnastics or yoga. If the pain persists after the removal of the adhesions, the doctor must be consulted again. While Asherman syndrome is not life threatening, medical steps must be taken and self-help measures undertaken, otherwise the symptoms will worsen over time.