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Asherman’s Syndrome

“I think I am pregnant," she told her boyfriend anxiously and desperately. “I have tested the urine three times and they are all positive!” He was unprepared and shocked. R, who was 24 years old, came from a family where her parents divorced when she was 5. Without the support of her family and boyfriend, she decided to abort the baby. The abortion was performed about ten months ago.

Three months following the procedure, her periods did not resume. She was concerned that she might be pregnant again, though the urine pregnancy test was repeatedly negative. She went back to her gynaecologist twice who gave her medications to induce menstruation. Still the menses did not come. When R saw me for a second opinion, she looked worried and confused. “Doc, what is wrong?” she kept asking.

After a thorough vaginal examination, a pelvic ultrasound scan and blood hormonal tests, I told her that she was probably suffering from Asherman’s syndrome, a condition where there is extensive scarring in the womb. This was confirmed by hysteroscopy, a procedure in which a tiny telescope is introduced into the womb to visualize it. The scars were freed surgically and an intra-uterine device (IUCD) inserted to prevent the walls of the womb from sticking together and forming scars again. She was also given medications to help the womb lining heal for the next 3 months. Her periods resumed after the treatment and she was well when she came for her review recently.

Asherman’s syndrome (AS) is a condition where there is injury to the lining of the womb with formation of extensive scars. It is a rare condition and occurs most often following an abortion as in R’s case. Some may result from overzealous curettage to remove the contents of a miscarriage or retained placental tissues following a delivery. Occasionally, pelvic infection, radiation treatment of womb cancers and uterine surgery for the removal of fibroids may cause AS. Very rarely it may be due to tuberculosis. Patients typically have a sudden onset of light or absent menses following the surgical procedure. Some may experience monthly menstrual cramps, repeated miscarriages and /or infertility.

The diagnosis of AS is by hysteroscopy. X-ray imaging technique (Hystero-salpingogram) using radio-opaque dye to visualise the uterine cavity has also been used. Treatment involves cutting and removing the scar tissues through the hysteroscope. After the scar tissue is removed, the uterine cavity is kept open by the insertion of an IUCD to prevent scars from returning. Oestrogen tablet is prescribed to help the uterine lining heal and antibiotics given to prevent infection.

Women who are infertile as a result of AS may be able to conceive after treatment. Treatment success depends on the severity of the condition and how well the lining of the womb rebuilds. Those who successfully conceive may carry the pregnancy to term. But they have to be monitored carefully, as they are at a higher risk of developing a low lying placenta (placenta previa) and/or an adherent placenta (placenta accreta) during pregnancy with serious consequences.

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