Asherman's syndrome: scar tissue inside the womb

Asherman’s syndrome in plain language

The cavity of the womb is normally a smooth, open space lined by the endometrium, the lining that thickens and is shed each month. In Asherman’s syndrome, bands of scar tissue (intrauterine adhesions, also called synechiae) form inside the cavity and join its walls together. Depending on how extensive they are, the adhesions may affect a small area or close off much of the cavity, and the lining in the scarred areas may be thin or damaged.

Asherman’s syndrome usually follows damage to the base layer of the lining, from which the lining regrows each month. It most often follows surgery to the lining soon after a pregnancy, such as surgical management of a miscarriage or removal of placental tissue after birth. It can also follow other operations inside the womb, a caesarean section, or infection. Sometimes no clear cause is found.

Symptoms

• periods that become much lighter, or stop altogether, after surgery or a pregnancy
• cyclical pelvic pain without bleeding, when blood is trapped behind the scar tissue
• difficulty conceiving
• miscarriage, including recurrent miscarriage
• in pregnancy, a higher chance of problems with the placenta

Some women have no symptoms, and the adhesions are found during investigations for fertility or after failed embryo transfers.

How I assess Asherman’s syndrome

I start with a careful history, including any previous pregnancies and procedures inside the womb, and your plans for a family. At Parkside Hospital and the CRP Clinic I can perform an ultrasound scan during the consultation, often including a three-dimensional view of the cavity, so we can usually discuss the findings at the same visit. The scan shows the thickness and pattern of the lining and can suggest where adhesions lie.

A hysteroscopy (looking inside the womb with a slim telescope) confirms the diagnosis and shows how extensive the scarring is. When the scan already points clearly to adhesions, I usually plan a hysteroscopy at which I can both confirm and treat them.

If you have scans, hysteroscopy reports or photographs from elsewhere, please bring them or send them to my secretary, Helen, before your appointment.

Treatment options

I will explain every reasonable option, including no treatment, and leave the decision with you. If the adhesions are causing no symptoms and you are not planning a pregnancy, treatment may not be needed. For most women with symptoms, or who hope to conceive, the treatment is surgery to divide the scar tissue and restore the shape of the cavity.

Hysteroscopic division of adhesions

I divide the scar tissue by hysteroscopy, through the cervix, so there are no incisions on the abdomen. Using fine instruments passed through the hysteroscope, I separate the walls of the cavity, cutting the bands of scar tissue while preserving as much healthy lining as possible.

When the adhesions are dense, or much of the cavity is closed, I use ultrasound guidance during the procedure. The ultrasound shows the outline of the womb as I work, which helps me to guide the procedure and reopen the cavity as safely as possible.

After the procedure

Preventing the adhesions from forming again is as important as dividing them. I routinely place an anti-adhesion gel (hyaluronic acid gel) in the cavity at the end of the procedure, to keep its walls apart while the lining heals. Randomised trials have shown that this reduces the chance of adhesions forming again. Depending on the severity, I may also recommend:

• a course of hormonal treatment to encourage the lining to regrow over the raw areas
• a second-look hysteroscopy a few weeks later, to check healing and divide any new adhesions while they are still soft
• in some cases, a temporary device placed in the cavity to keep its walls apart

What to expect from treatment

The outcome depends mainly on how severe the scarring was and how well the lining recovers. For mild and moderate adhesions, most women find their periods improve and many go on to conceive. Severe Asherman’s syndrome is more difficult to treat, more than one procedure is often needed, and the chance of a successful pregnancy is lower. I will be honest with you about what is realistic in your case.

A pregnancy after treatment for Asherman’s syndrome carries a higher chance of complications, particularly with the placenta growing too deeply into the wall of the womb. I will make sure your obstetric team knows your history so that your pregnancy can be monitored appropriately.

What the procedure involves and recovery

The procedure is usually carried out as a day case, under general anaesthetic or sedation, and takes between fifteen minutes and an hour depending on the extent of the scarring. You will receive full written information beforehand.

Afterwards, mild cramping and light bleeding for a few days are normal. Most women return to work within a day or two. The main risks are infection, bleeding, perforation of the wall of the womb (which is uncommon and usually heals on its own, although it occasionally needs a laparoscopy to check for injury to nearby organs) and the adhesions forming again. I see you afterwards to go through what I found and to plan the next steps.