Friday, July 3, 2009

Introduction: why blog about Asherman's syndrome?

This blog is dedicated to documenting and commenting on information and misinformation relating to Asherman's syndrome and its main cause, surgical evacuation of the uterus. I will also document information and misinformation about promising alternatives to surgical evacuation, particularly misoprostol which is a safe and effective non-invasive drug. Hysteroscopy is another alternative to D&C for retained products of conception from an incomplete miscarriage or retained postpartum placenta, as it allows the surgeon a direct view inside the uterus during surgery. Both are underutilized by doctors who treat early pregnancy failure.

The misnomer of Asherman's syndrome actually refers to a frequently iatrogenic (caused by medical treatment) condition known as intra uterine adhesions or IUA (ie adhesions inside the uterus) caused by injury to the endometrium (lining of the uterus). This injury produces scars on the delicate endometrial tissue which lead to adhesions and/or fibrosis of the endometrium leading to impaired fertility and future obstetric complications if pregnancy occurs. Although estimations are difficult due to a lack of awareness about the condition by doctors and patients alike, it is thought to affect approximately 5% of women. Over 90% of cases are caused by surgical evacuation of the uterus- this includes procedures and terms such as dilation and curettage (D&C), dilation and evacuation (D&E), suction curettage/evacuation, MVA (manual vacuum aspiration), or simply curettage. For the sake of simplicity I will refer to all types of surgical evacuations of the uterus collectively as "D&C". Asherman's syndrome can be caused by any uterine surgery and rarely by endometrial tuberuculosis infection, however my focus is on D&C because this is still considered 'standard care' for miscarriage management in the US, Australia and many other countries.

All or some of these procedures continue to be used for a host of gynecological conditions and pregnancy complications including:

-postpartum retained placenta
-endometrial biopsy
-heavy/abnormal uterine bleeding
-endometrial polyps
-investigation of gynecological cancers
-Asherman's syndrome (absolutely NOT the correct treatment!!!)

There are safer and often cheaper alternatives to D&C for all of the above.

Surgical treatment for Asherman's syndrome exists (hysteroscopic adhesiolysis and estrogen therapy), however overall birthrates remain disappointing for moderate to severe cases (around 30-40%). There is also very little research on optimizing and comparing treatments. Meanwhile there are many randomized controlled trials (RCTs) on using misoprostol for miscarriage management. Prevention is therefore the more logical approach.

I hope to make women aware of the dangers of this procedure and the existence of alternatives. There is a lot of misinformation about the condition due to both a lack of awareness and medically unfounded over-optimism about treatment outcomes.

Over the years women have become aware of the abuse and misuse of hysterectomies and alternatives thanks to activism. This blog aims to make people aware of a similar situation occurring with D&C. It is my hope that one day drugs will replace D&C worldwide for miscarriage management, or at least be offered as a first line of treatment.

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