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Asherman's Syndrome

Asherman's syndrome refers to the formation of adhesions or scar tissues on the endometrium (uterine lining). Most often endometrial scarring occurs as a result of scraping of tissue from the uterine wall while performing dilation and curettage (D& C). Though D&C is mainly responsible for adhesions, uterine surgery and severe infections of the endometrium such as genital tuberculosis are some of the other factors that cause Asherman's syndrome. Normally, Asherman's syndrome shows up with decreased menstrual flow or even amenorrhea, cramping, abdominal pain and is even associated with infertility and recurrent miscarriages.


Causes of Asherman's syndrome

D&C procedure is performed for miscarriages, excess bleeding, elective abortion or to remove the retained products of conception. Some gynecological disorders call for uterine surgery. Sometimes trauma occurs to the uterine lining while performing D&C procedure or other surgery. In case of damage, the wound begins to heal and in the process, fuses with the affected portion causing adhesions. The risk of Asherman's syndrome increases with repeated D&Cs.


Symptoms of Asherman's syndrome

Infertility
Menstrual disorders such as Hypomenorrhea or amenorrhea
Repeated miscarriage
Pelvic pain as scar tissue blocks the menstrual flow.


Diagnosis and treatment of Asherman's syndrome

Hysteroscopy is the widely used method to diagnose the Asherman's syndrome as it allows the doctor to have a complete view of the uterus directly. However other methods such as sonohysterography (SHG), hysterosalpingogram (HSG) and transvaginal ultrasound examination are also used to evaluate adhesions. Blood tests are done to detect tuberculosis or schistosomiasis.

Asherman's syndrome is normally treated with surgery to remove the adhesions or scar tissue. The surgery involves hysteroscopy procedure wherein scar tissue is removed by using small instruments, micro scissors and a camera. Once the scar tissue is removed, an intra uterine balloon is placed inside the uterus to keep the uterine cavity open. This procedure aids the healing process and prevents adhesions from returning. Patient may also be prescribed oral estrogen medications for promoting growth of regular uterine lining. Patient may be called in for review hysteroscopy after two weeks of the procedure to make sure that there is no reformation of adhesions.

Endometrial Ablation

Heavy menstrual bleeding may happen due to underlying conditions such as hormonal imbalance, uterine polyps and ovarian dysfunction. Menorrhagia is also an inherited disorder as it is associated with blood clotting impairments like Von willebrand's disease. In most cases, endometrial biopsies are done to determine histological overview of the conditions. Many treatment options are suggested depending upon the age, lifestyle and medical history of the patient. Among many prophylactic measures, endometrial ablation or uterus ablation is increasingly becoming the most preferred method.


The inner layer of the uterus called as the endometrium is removed using the diathermy electrode. The patient is subjected to general anesthesia during the procedure. Careful examination of the uterine wall is done to identify any underlying uterine disorders. The electrode is 4mm and it helps in cutting of the endometrium. In addition to this, the myometrium is also destroyed to eliminate the underlying endometrial basal cells.

The basal cells of the endometrium are also called basalis. They enable the multiplication and thickening of the endometrium forming the superficial layer of the endometrium which is shed out. The walls of the uterus are examined for bleeding points and then the patient is sent to the recovery room. Other modern techniques such as the administration of microwave endometrial ablation, cryoablation, diode laser phototherapy are considered.


Endometrial ablation is not advisable for patients who might be in early pregnancy, have a history of uterine cancer and menopause. Women who undergo endometrial ablation have a chance of conception; however there is a possibility of miscarriage. This happens because the uterine lining has been removed.

Endometrial ablation is also recommended as an alternative to hysterectomy. Endometrial ablation is also done on an outpatient basis with a given recovery time. The results of the endometrial ablation treatment include absence of menstrual bleeding. In some cases, there is a possibility of reduced bleeding. Consult a doctor in the case of spotting to identify the emergence of conditions such as fibroids or polyps of the uterus. Endometrial ablation procedure is widely administered among women in the age group of 30 to 45.

Endometrial Resection : The Loop Electrosurgical Excision Procedure(LEEP) is used to destroy the uterine lining. The use of LEEP is faster and provides faster recovery than any comparable surgical procedure.


Complications of Endometrial Ablation

The most significant complication is perforation caused to the uterus. In these cases laparoscopy is done. Other possibilities include perforations to organs such as the bladder, blood vessels and the organs in pelvic region.

The fluid absorption during the endometrial ablation procedure may result in the lowering of blood salt levels causing damage to the lungs and brain. In post-operative cases, vaginal bleeding is common for a few days. However, if the discharge or bleeding from the vagina is associated with foul smell, infections of the uterus are suspected. Women who have undergone the endometrial ablation procedure are generally advised to take progestogens which help in reducing the risk of uterine cancers. Sexual intercourse is advised only after two weeks to prevent vaginal bleeding or pain.


Menstruation

Menstruation is the monthly shedding of the endometrium or uterine lining. The menstrual cycle is controlled by rise and fall of hormone levels. In anticipation of an egg that is released during a month, the uterine lining is thickened with blood, tissue and fluid. This is in preparation for fertilization and possible pregnancy. When no fertilization occurs, the egg along with the uterine lining are shed throuh the cervix and into the vagina. This menstrual period occurs nearly once every 28 - 35 days. Each time it lasts for about 3 - 7 days.

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Bibliography / Reference

Collection of Pages - Last revised Date: November 15, 2019