Asherman’s syndrome—also known as Fritsch syndrome or Fritsch-Asherman syndrome—is the formation of scar tissue (adhesions) on the lining of the uterus following uterine surgery. This rare condition can cause menstruation to be painful or otherwise abnormal, or it can prevent menstrual periods altogether. Asherman’s syndrome can also cause infertility or miscarriages in subsequent pregnancies.
Asherman’s syndrome was first described by German gynecologist Heinrich Fritsch in 1894. Fritsch’s description was elaborated upon in 1948 by Joseph Asherman, an Israeli gynecologist.
The symptoms of Asherman’s syndrome—the absence of menstrual periods (amenorrhea), infertility, or repeated miscarriages—can often have other causes, but Asherman’s syndrome may be suspected if the affected woman has recently had an abortion, a Cesarean section delivery, or a dilation and curettage (D & C) procedure. Of these procedures, dilation and curettage—which is undertaken in order to remove residual fetal tissue following an abortion or miscarriage—is the most common cause of Asherman’s syndrome. Most cases involve women who have had multiple D & C procedures. The incidence of Asherman’s syndrome rises with the length of time that elapses between the miscarriage or abortion and the D & C procedure.
Recurrent pain along with absent periods is another reason to suspect Asherman’s syndrome. Some patients experiencing amenorrhea report intense pain at the time of the month when they would normally be getting their period; this can be a sign of Asherman’s because the uterine scarring interferes with the normal monthly shedding of the uterine lining, and also the adhesions can block the cervical opening. It is important to remember, however, that the severity of the condition cannot be judged by the presence or absence of pain, nor by whether the patient is getting her period. The scarring and adhesions are not always painful, and they will only interfere with menstruation if they are placed so as to block the cervix or cause blood to become trapped inside the cavity.
Causes and Risk Factors
Asherman’s syndrome is usually caused by surgery, although in rare cases the trauma that triggers it can be brought on by a severe pelvic or uterine infection (which can sometimes be brought on by surgery).
In most cases, however, this condition occurs as a result of surgery involving the uterus, including:
- Dilation and curettage
- Dilation and evacuation
- Cesarean section
- Treatment for fibroid tumors in the uterus
When the uterus is traumatized, whether by injury, infection, or surgery, the trauma stimulates the normal healing process, which can sometimes cause the injured tissues to fuse together, forming the scars and adhesions described above. In some cases the walls of the uterus may stick to one another.
Diagnosing Asherman’s Syndrome
Diagnosis of this condition usually involves a procedure known as hysteroscopy. This procedure involves the use of a device called a hysteroscope—a thin fiber-optic device fitted with a light and a camera—to examine the cervical canal and the inside of the uterus. In some cases the doctor may also want to conduct a transvaginal ultrasound with salt-water called a saline hysterogram (sometimes also called a hysterosonogram).
Treating Asherman’s Syndrome
Asherman’s syndrome is treated surgically. In some cases the surgery may be performed with the same device used in the diagnosis, the hysteroscope. The scar tissue adhesions are cut away, and the surgeon temporarily implants a small balloon (or sometimes an IUD) in the uterus to keep the uterine cavity open and prevent the walls from touching. This balloon will usually be removed within a few days, and while the patient is recovering she may be prescribed estrogen supplements to promote healing. If the scarring was caused by an infection, antibiotics may also be prescribed.
If the patient has no desire to bear children, sometimes the best treatment for Asherman’s is a hysterectomy. Since the uterus is usually of normal size, many patients are ideal candidates for total laparoscopic hysterectomy (TLH), a minimally invasive procedure akin to a laparoscopic gall bladder removal. The recovery from this procedure is much faster than for traditional open hysterectomy.
Complications following surgery are rare, but they can include perforation of the uterus, bleeding, or infection—ironically, the very sorts of conditions that may have given rise to the syndrome in the first place.
In most cases the prognosis is very good, at least in terms of the scarring and the symptoms it causes (pain and amenorrhea). Surgical treatment of Asherman’s syndrome has a very high rate of success, although multiple procedures are sometimes necessary. While the rate of success for curing infertility caused by Asherman’s syndrome is not quite so high, many women do find that they are able to conceive after having surgery for this condition. Generally speaking, the outlook for the patient’s fertility depends on the severity of her condition.
Incidence of Asherman’s Syndrome
Because it is not detectable with routine procedures such as ordinary pregnancy ultrasound, Asherman’s syndrome is thought by some to be under-diagnosed.