Thursday, July 9, 2009

(Opinion) Asherman's syndrome and abortion: A convenient misconception?

In my last post I brought up the issue of abortion because usually the topic of Asherman's syndrome only gets mentioned by the public in the context of abortion which is very misleading. I just want to remind you that the intention of this blog is not about abortion, but about Asherman's syndrome, D&C safety, medical ethics and alternatives to D&C.

As I mentioned in my last post, one reason for the misconception linking Asherman's syndrome only to abortion is that doctors rarely address the point by clarifying that:

-There are ways to perform abortions without the use of surgery (D&C), therefore safely, so the point is irrelevant, and

-The same surgery as that used for abortions (D&C) is used commonly in gynecology and obstetrics.

In this
youtube clip Dr Paul Indman, who is experienced in the treatment of Asherman's syndrome, states that the condition is more often seen in women after a D&C for miscarriage or retained placenta, especially when repeated, than in women who have had a D&C for abortion.

Despite this medically known fact, this and many other myths about Asherman's syndrome continue to linger. Please watch my youtube clip.

Many women who have had Asherman’s syndrome from a D&C, myself included, feel strongly that D&Cs should not be performed, whether they are for miscarriages, diagnostic purposes or for abortion. Yet many doctors-even some Asherman's syndrome experts- are adamant that D&Cs can never be replaced, something which I as a PhD scientist and student of Public Health and Evidence Based Medicine know for a fact is untrue after having read several clinical trials on
misoprostol use for miscarriage management (1)(2)(3)(4)(5). In some parts of Europe misoprostol has gained acceptance as a valid alternative to D&C. Perhaps the absence of anti-abortion activists and strong religious influences accounts for the widespread availability of misoprostol and mifepristone in Switzerland and some parts of Europe.

Therefore doctors continue to perform D&C even though it is known that complications can occur, and that there are some good alternatives including drugs for uterine evacuation (eg. miscarriage, retained placenta, abortion) and
hysteroscopy for uterine surgery (eg. fibroids, polyps) and in selected cases for miscarriage management (6). Only about 15% of US Gynecologists are trained in office hysteroscopy. The drug misoprostol, for example, is very cheap and there are no surgery related costs including anesthesia or operating room costs. Yet women in developed countries continue to have their reproductive organ-their endometrium-mutilated by the continued use of D&Cs.

Could it be that many doctors see it's in their best interest to stick to D&Cs which are more financially rewarding than prescribing drugs and less skill intensive than hysteroscopy? It may even be convenient that this whole D&C safety issue can be covered up by the abortion debate. There's nothing like a moral controversy to hide inconvenient truths. It is also a good way to deny responsibility for what is really an iatrogenic condition, avoiding law suits. In fact, doctors refrain from using the word 'iatrogenic' when describing Asherman's syndrome, yet it is more often than not the case. Their attitude towards abortion is different though. Abortion is a woman's choice, and they reason that if she chooses to have an abortion and her uterus ends up scarred by the D&C, it was the result of her own choice (not really because anyone should be given informed consent, but that is how some people might see it). They may feel it is more important to warn women about the risks of abortions- which she could (and perhaps in their mind 'should') choose not to have- than a miscarriage, which a woman has no control over. Or they may reason that women who abort should be given drugs instead of surgery to reduce the risk of infertility resulting from her own decision. I saw this inconsistent line of thinking in a paper and felt it was offensive. The medical community is doing a big disservice to women when it does not point out that these complications happen to women who never chose to miscarry, or have D&Cs imposed on them for other reasons. It is equally unacceptable for women to develop fertility and/or obstetric complications from a D&C for treating a miscarriage or for other reasons that were not of her own choice. All women need to be protected equally from potential harm.  

Whether the present situation is due to ignorance, moral confusion or denial on the part of many doctors about possible complications from D&C and alternative treatments, something needs to be done to change current mentality and awareness of the problem. Already over a century has passed since the link between Asherman's syndrome and D&C was first made (7). In some countries at least, blind surgery continues...and worst of all, possibly due to a warped argument of 'morality'.


(Please note that in medical terminology, 'abortion' is often used s a synonym for 'miscarriage' and does not refer to elective termination...which probably fuels myths among people who don't understand this.)

1. Moodliar, S, Bagratee, JS, and Moodley, J. Medical vs. surgical evacuation of first-trimester spontaneous abortion. Int J Gynaecol Obstet 2005;91(1):21-6.

2. Bique, C, Usta, M, Debora, B, Chong, E, Westheimer, E, and Winikoff, B. Comparison of misoprostol and manual vacuum aspiration for the treatment of incomplete abortion. Int J Gynaecol Obstet 2007;98(3):222-6.

3. Weeks, A, Alia, G, Blum, J, Winikoff, B, Ekwaru, P, Durocher, J et al. A randomized trial of misoprostol compared with manual vacuum aspiration for incomplete abortion. Obstet Gynecol 2005;106(3):540-7.

4. Shwekerela, B, Kalumuna, R, Kipingili, R, Mashaka, N, Westheimer, E, Clark, W et al. Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. Bjog 2007;114(11):1363-7.

5. Dao, B, Blum, J, Thieba, B, Raghavan, S, Ouedraego, M, Lankoande, J et al. Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa. Bjog 2007;114(11):1368-75.

6. Goldenberg, M., Schiff, E.' Achiron, R.' Lipitz, S.' Mashiach, S. Managing residual trophoblastic tissue. Hysteroscopy for directing curettage. J Reprod Med. 42(1)26-8.

7.Fritsch, H. Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung Zentralbl Gynaekol 1894;18:1337-1342.

No comments:

Post a Comment