Uterine Adhesions and Asherman's Syndrome

What’s going on inside your uterus is not a thought that crosses most of our minds on a daily basis. Sure, we are reminded of that organ every month when “Aunt Flo” arrives, but unless you are a medical student, a gynecologist, or a woman who is having problems getting or holding on to a pregnancy, you are probably not all that aware of your uterus. But news flash…the uterus is a pretty important organ with an essential role in reproduction.  

This may come as a surprise, but it is actually a muscle. Yup, that’s why you get those monthly cramps—and why anti-inflammatories like ibuprofen work so well at taking them down a notch (P.S. it’s also partly why acupuncture and supplements like magnesium help too!). The uterus’s primary job is to carry a pregnancy. And not to get all science-y or medical, but when you think about how the uterus grows and shrinks, thickens and sheds, and carries and delivers a tiny human, it’s sort of unbelievable. While its marathon is not 26 miles, it actually can go the distance for you several times in your life (depending on how many pregnancies you have). It goes from the size of an orange to the size of a watermelon, all in matter of nine months and then manages to push out a baby. Pretty unbelievable stuff! 

So, how can you tell if your muscle is in tiptop shape? Obviously, given its location, you can’t stare at it in the mirror as it flexes! The best indication of how your uterus is functioning is the arrival of your monthly period. For women who are not on hormonal contraception (pills, patch, IUD), you should expect a period about every 28-30 days. While the regularity of your period is not the focus of this piece, and you shouldn’t call your GYN to report a 27- vs. a 32-day cycle, no period or very minimal/light flow might be evidence that something is off inside your uterine cavity. Changes in the quality of your flow (heavy vs. light) or number of days of bleeding can also be the signal to seek help.  

The uterine cavity (a.k.a. womb) is composed of two layers: the basalis and the functionalis. Think of the basalis as the bottom or the base and the functionalis as the top, or the functioning layer. Every month, when a woman menstruates, she sheds her functionalis, or functioning part. After its departure, the basalis works to replenish this very important layer. When damage occurs, the functionalis is the first to take the hit, and as you can imagine, the deeper the damage, the worse the situation.  

And while the uterus taking some damage at the first layer its mostly repairable, damage sustained down to the basalis can cause irreparable harm. If you lose the base layer, your body will be compromised in its ability to regrow and repair the upper layer. So bottom line, varying degrees of insult can have varying degrees of injury. Maybe it really is all about the base… 

However, while scar tissue in the uterus can translate into no period or light periods, what your uterus does is often a reflection of the message that your ovaries (and actually your brain) are sending its way. That’s why women who don’t produce estrogen for any number of reasons (too much exercise, too little food, or even menopause) don’t get a period. No estrogen = no thickening of the uterine lining. No thickening = no period. The estrogen produced by your ovaries stimulates the uterine lining to thicken each month.  So in many cases, women who are not getting a period have a functioning healthy uterus, it’s just not being stimulated by hormones. If the appropriate hormones are delivered in the appropriate fashion, all systems will be a go. Differentiating between the two and trying to figure out where the roadblock is, is actually fairly easy.  

While it does take a visit to your OB/GYN and in some cases a fertility specialist, finding out who “did it” is simpler than a game of Clue. Professor Plum in the study with a candlestick it is not. Getting a good history focusing on previous pregnancies, particularly how they ended (D&Cs, abortions, retained placenta, and even a C-Section) is of the utmost importance. These are the flashing red lights for who may have scar tissue lingering in their uterus that is preventing a future pregnancy from occurring. Asherman’s syndrome is the medical term for this condition.  

The uterus can develop scar tissue in response to some sort of an injury. Just like any scrape, cut, or bruise, the more significant the injury that caused it, the more significant the scar. While the injury is most frequently a D&C (dilation and curettage) after a pregnancy (be it a miscarriage, an abortion, or a piece of placenta that remained inside after a delivery), it can also result from other causes (i.e. an IUD or an infection).  

The degree of scarring can be determined by looking inside the uterus with a variety of imaging tests (ultrasound, hysterosalpingogram, hysteroscopy). It can also be suggested by how light, heavy, or absent your period is. For example, if the scar tissue is severe, it could have damaged most of the uterine cavity; this would cause minimal or no bleeding (medically termed amenorrhea). So while the ovaries are sending all the right signals, the uterus lacks the ability to respond to the message.  

Even the most extreme cases of scarring can frequently be fixed. You just need to find a good doctor who has a good idea how to navigate the situation. Uterine scarring requires surgery to remove the adhesions (a.k.a. scar tissue) and restore the cavity (a.k.a. womb) to its original shape. While it can make a major difference in your baby-bearing ability, it is a fairly minor procedure, an outpatient procedure that lasts no more than a couple of hours.  During the procedure, the cervix is dilated to allow the placement of a camera. The camera is connected to a monitor (don’t worry; there will be no broadcasting or streaming!), which allows the surgeon a front-row seat to what is going on inside. After identifying the damaged tissue, instruments are threaded through a channel on the camera. The surgeon’s instrument of choice (we like tiny scissors) is used to gently remove the scarring. Following the procedure, a tiny catheter is placed into the uterus to keep the uterine walls from touching each other while they heal for the next five to seven days. Additionally, while the catheter is camped out in your uterus, you will start about a 21 to 28-day course of estrogen and progesterone. The theory behind this cocktail, catheter, and medications, is to go full force on healing, rebuilding a healthy uterine lining. This is also an excellent time to incorporate acupuncture into the mix as it can help promote blood flow to the uterus while it heals. Some Chinese herbal formulas can also help with rebuilding and thickening the uterine lining.

From the Eastern perspective, scar tissue in the uterus is considered Blood Stasis…the blood gets stuck after trauma (like a miscarriage, birth, or d&c) and can’t flow well. This pattern presents in cases where the menstrual flow is dark and/or clotty with cramping. Light periods associated with Asherman’s can also be seen as Blood Deficiency, especially when the flow is more red and there isn’t much cramping. When there is no source of trauma (aka when light periods might be from low estrogen and not scar tissue), blood deficiency is often the culprit. Herbs, acupuncture points and dietary changes to nourish and move the blood help these patterns, especially to encourage healing after surgical interventions like we discussed above.

So does it work? Can even the most damaged of uteri be remodeled? In most cases, yes….mild and moderate cases of uterine scarring are fairly responsive to treatment. Most women go on to have monthly menses (can’t believe you would ever cheer about that, right?) and conceive. Subsequent pregnancies can be at higher risk for placental implantation problems (placenta previa, accreta), but most go the distance without any issues.  

Severe cases can present even the most experienced surgeons with a formidable challenge, however. While it’s often not the removal of the damaged tissue that keeps the red light red, it’s the uterus’s ability to restore good healthy tissue that keeps things at a halt. If damage was sustained all the way down to the basalis, restoring a functioning cavity can be nearly impossible. In such cases, although recreating a functional cavity may evade even the most gifted surgeons, pregnancy can be achieved with the use of a gestational carrier.  

Many things in life happen outside of our control. Even the most type-A of us who fight to plan and control every minute (trust us, we get it!) can’t script how our uterus will react to an injury. However, we can outline a plan if something should seem off. If you feel that something is not right, go speak to your GYN or fertility specialist, as well as your acupuncturist and leave out no details. We need to have all the facts when it comes to your medical history so we can do the right tests and get to the bottom of things. Together, we can come up with a road map to navigate a path through even the roughest of waters. It may include a few trips to the operating room, a few rounds of estrogen/progesterone, and some herbs and acupuncture, but ultimately with time, the uterus, like the rest of us, can heal and repair.