Asherman’s Syndrome: A Challenge To Woman Hood.
By Egbere Onyeka Barnabas (RN, BNSC).
Asherman’s syndrome is a rare acquired uterine disease that causes adhesions (scar tissues) to form in the uterus. The disease may be mild with adhesion occurring in only a small portion of the uterus, or severe when the adhesions are so extensive, they cause the front and back wall of the uterus to stick to one another [adhesions are formed].
The adhesions may be thick or thin spotty or joined. This condition is named after Dr. Abraham, an Israeli gynecologist who first described the condition in the mid 20th century when he noted that some women who had surgical treatment around childbirth subsequently stopped having their menstrual cycles.
Incidence
- A 1998 study in the netherlands found 40% Women in the study who under went a dilatation and curettage (D&C)
- Other studies suggest that 1 in 100 postpartum D&C’s result in Asherman’s syndrome.
- It affects women of all race and age equally.
Causes:
- Trauma: Trauma to the basal layer, typically after a dilatation and curettage (D&C) performed after a miscarriage, or delivery, or for surgical termination of pregnancy, can lead to the development of intrauterine scars resulting in adhesions that can obliterate the cavity to varying degrees.
- Surgeries: Asherman’s syndrome can result from uterine surgeries such as removal of fibroid tumors (Myomectomy), pelvic surgeries including caesarean sections, and other causes such as IUD’s, pelvic irradiation.
- Infection: Uterine infections such as pelvic inflammatory disease can predispose an individual to Asherman’s syndrome if not well treated. Others are schistosomiasis (Genital form), genital tuberculosis, these can be significant causes of severe intrauterine adhesions with resultant obliteration of the uterine cavity, which is difficult to manage.
- Other causes include: Endometriosis, radiation therapy etc.
Diagnosis
Asherman’s syndrome is believed to be under-diagnosed, because it is undetectable by routine diagnostic procedure such as ultrasound.
- Hysteroscopy or a Hysterosalpingogram (HSG): The best way to diagnose Asherman’s syndrome is by using a diagnostic hysteroscopy or a hysterosalpingogram. This procedure is done at the endoscopic theatre to reveal the extent of the scar formation in the uterus.
- History Taking: The history of a pregnancy even followed by a dilatation and curettage leading to secondary amenorrhea or hypomenorrhoea is typical.
- Transvaginal Ultrasound: Asherman’s syndrome is believed to be under-diagnosed, when a procedure like ultrasound is used. Although some developing countries like Nigeria are still using it, but its accuracy is low.
- Magnetic Resonance Imaging (MRI): It can be helpful as a supplementary diagnostic tool, especially when the adhesions involves the endo-cervix.
Signs and Symptoms
- Menstrual Changes: lighter periods than usual or non at all
- Pain or cramping around the time of period but with little or no blood.
- Endometriosis, caused by a backflow of blood from the uterus.
- Unexplained infertility may be present (Valley and Sciarra, 2009).
Challenges of Asherman’s Syndrome
Asherman’s syndrome can lead to infertility in a number of ways. No two causes are identical and it can manifest as infertility, according to how and which parts of the reproductive anatomy that is affected.
Below are some ways that this disease condition can pose as a threat to womanhood.
It challenges womanhood, by resulting to infertility which occurs due to adhesions occluding the tubal ostia, uterine cavity, or the cervix, thereby interfering with the migration of sperm or implantation of the embryo.
Another possible way Asherman’s syndrome can result in infertility is by causing endometriosis. Some authors have noted that women with extensive adhesions either in the uterus or cervix blocking menstrual flow, later develop endometriosis.
Many women who have had Asherman’s syndrome develop a thin endometrium, even after surgical correction. The thin endometrium may be unresponsive to hormones and may lead to infertility in form of implantation failure.
Treatment
They are three basic principles in the management of Asherman’s syndrome/intrauterine adhesions.
- The first principle is adhesiolysis which is done by blindly using a uterine sound or curette.
- The second principle is separation of the uterine wall and the purpose of this is to prevent recurrence of the intrauterine adhesion after adhesiolysis. This can be achieved with the use of a lippes loop size “D” or intrauterine insertion of a paediatric foleys catheter. The use of the paeditric foleys catheter is presently commoner because of the non-availability of the lippes loop. The catheter or uterine ballon is left in-utero for a maximum of 7 – 10 days.
- The third principle is regeneration of the endometrial lining and this is done by placing the patient on estrogen and progesterone, so as to encourage growth of the lost endometrial lining. These drugs are used for a period of three months (At least) A recent study suggests that treatment with tocopherol (I,e vitamin E) and pentoxifyllin may help to thicken the endometrium, improving implantation after surgery.
Follow – up tests (HSG, Histeroscopy or SHG) are necessary to ensure that adhesions have not reformed. Further surgery may be necassry to restore a normal uterine cavity. According to Valley and Sciarra (2009), among 61 patients, the overall rate of adhesion recurrence was 27.9% And in severe cases, this was 41.9%.
Conclusion
As a consequence of the above, many women who have untreated Asherman’s syndrome are either unable to conceive or suffer from repeated miscarriages. It is therefore pertinent that those suffering from any form of infertility should seek medical help to determine if they have Asherman’s syndrom, and if the diagnosis is confirmed, a specialist should be consulted who should manage it with best methods available, with a follow – up hysteroscopy or HSG. It must be confirmed that adhesions have not reformed again prior to trying to conceive again. It is also better avoiding Asherman’s syndrome by using alternative methods other than dilatation and curettage.
Reference
- Valley and Sciarra (2009): systemic review and metanalysis of intrauterine adhesions after miscarriage; prevalence, risk factors and long term reproductive outcome.; Human reproductive update 20(2).262-78. Doi: 10:1093/humapd/dmt045.pmd 24082042
• Edited by Ayinla Daniel Rn (Chief Editor Care City).
• Photo credit: Artem Kovalev @unsplash.
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