Some months ago, a fellow Asherman’s syndrome (AS) sufferer who writes the blog Alternative Asherman’s had a missed miscarriage after AS and wrote of her experience (Three steps backwards) using misoprostol, linking it to the blog about my own experience using misoprostol. I feel it is necessary to clarify certain points in her experience as they may be inadvertantly misleading and appear to implicate misoprostol in what apparently ensued. She has also since updated her blog to clarify her interpretation of her experience.
Misoprostol is a non-invasive uterotonic drug that expels the uterine contents in a way that is analogous to a natural miscarriage. Scarring and subsequent adhesions are the result of physical injury (or severe infection) to the basal endometrium. In fact management of miscarriage with misoprostol has been shown to prevent adhesion formation compared to blind D&C (Tam WH, Lau WC, Cheung LP, Yuen PM, Chung TK. J Am Assoc Gynecol Laparosc.2002; 9 (2): 182–185.). Misoprostol can be used to expel the contents of the uterus for either pregnancy termination, after a missed or incomplete miscarriage has occured or for labour induction. It also dilates the cervix and is useful prior to hysteroscopic surgery. Unfortunately, misoprostol is often referred to as a 'pregnancy termination drug' despite its various uses.
With regards to misoprostol's efficacy it should be noted that she obtained Chinese herbs from her accupuncturist to help 'prepare her body for miscarriage'. (See her comment below). This is unnecessary. It is not advised to mix Chinese or any other alternative or over the counter drug/herb with the treatment prescribed by your qualified ObGyn. Any responsible qualified homeopath/alternative medicine practitioner (some are MDs) would not dispense drugs whose effects and interactions with drugs prescribed by another specialist is not known and has not been vigorously trialed. There is no regulation or standardization of alternative drugs (herbs, extracts, etc.) so their concentrations, compositions quality and therefore effects and interactions vary greatly. We don't know if using these herbs could have interfered with misoprostol's effect in some way (for example, reducing its efficacy by blocking the same receptors targeted by misoprostol).
She was told that she developed IUA after using misoprostol and prior to hysteroscopic surgery to remove retained products. Her hysteroscopic surgeon said that the RPOC from an incomplete evacuation led to fibrous scar tissue formation. While I have heard about this anecdotally, I have not seen any reports of women developing IUA from RPOC in the absence of severe infection. It is also difficult to reconcile the observation of dense scar tissue with products retained for just 5 weeks when scar tissue is not complete until about 8 weeks. Anecdotally, I personally had substantial retained products for 3 weeks after my second trimester miscarriage treated with misoprostol and did not develop IUA. RPOC and retained placenta can be managed conservatively (under medical supervision).
However, she does mention that she may have already had some recurrence of IUA before her pregnancy as her Obstetrician noticed what appeared to be synechiae on ultrasound. This appears to be an important clue.
She says that there were dense adhesions whereas she previously had had only mild adhesions at initial diagnosis.One possible way to explain the deterioration of her condition could lie in the initial treatment of her AS: she had a uterine cook balloon inserted following adhesiolysis. While I underwent the same procedure without any apparent complications like hundreds of others (a proportion of whom have gone on to have children), it is possible that if the stent was not removed properly, or if it somehow adhered to raw surfaces in the uterus, it could have caused damage on removal (the balloon is deflated and simply pulled out). This explanation would also be consistent with her ObGyn's observation of scar tissue during a prenatal scan. Note also that there is limited data from studies on the benefits of using the Foley catheter and IUDs after surgical lysis and no controlled or comparative trials on the Cook balloon. Some Asherman’s syndrome specialists even believe that stents can stunt endometrial regrowth.
A well researched and routinely used drug like misoprostol should not be treated with suspicion compared to many other medical and even pseudo medical treatments the same women undergo without questioning, from unproven and potentially harmful altnernative drugs to contraversial fertility therapies to treatments of Asherman’s syndrome on which there are comparatively less data and of a lower quality. This leads me to wonder whether it is the attitude of the treating doctor(s) which influences patients' perceptions of treatments. I agree that more doctors need to be trained in the use of misoprostol for miscarriage (and in particular among women with a history of AS) and that a followup hysteroscopy may be needed depending on clinical symptoms and gestational age at time of miscarriage to ensure there are no retained products of conception. Followup hysteroscopy may also be necessary in women with a history of AS if the miscarriage passed naturally as there is a possible tendency towards retained tissue from scarring. We already know that women with past AS are at an increased risk of abnormally invasive placentation such as placenta accreta. Retained tissue and placenta accreta may be different ends of a spectrum of abnormalities associated with placental invasion in a defective endometrium. Whether misoprostol is necessary to evacuate miscarriages that occur very early on in the pregnancy (prior to 7 weeks) is also questionable. These can be managed expectantly. It is especially risky to perform a blind D&C in women who already have suffered damage to their uterine lining. It is time for miscarriage management as a whole to be reviewed in light of advances in medical therapy and hysterosopic alternatives.
Showing posts with label curettage. Show all posts
Showing posts with label curettage. Show all posts
Tuesday, January 4, 2011
Friday, August 14, 2009
Treatment of Asherman's syndrome is not a panacea (Part I)
Not all that long ago Asherman’s syndrome patients may have been told to forget about ever having a(nother) child. Treatment has come a long way with the advent of hysteroscopy, hormonal treatment, stents and adhesive barriers. It’s not surprising that before these were available, success rates were very low and often more damage was incurred from ‘treatment’ resulting in worse outcomes. One of the reasons for this is that some doctors used to treat Asherman’s syndrome by performing a blind D&C to break apart intrauterine adhesions they couldn’t even see. It’s hard to imagine why anyone would think that performing the same procedure as the one which usually causes the condition could fix things, but lots of doctors did- and some continue to do so with disastrous consequences.
Some doctors might still have the attitude that anyone whom they cannot treat successfully should give up hope, even if they are not highly skilled or experienced in the treatment of intrauterine adhesions. However, a new and equally detrimental view is being encouraged among sufferers: that treatment has come so far that anyone who is diagnosed stands a very good chance of conceiving and delivering a healthy baby (provided they go to the right doctors). While it’s true that some doctors have much more training, experience and expertise in the treatment of Asherman’s syndrome, the harsh reality is that the overall success rate is not above 50% (and lower for the moderate to severe cases)- even with the best doctors. If anyone tells you that there are doctors who have higher success rates with moderate to severe cases than 50%, they are either not being truthful or simply don’t know (or prefer not to accept) the reality.
It’s a bitter pill to swallow, but women need to be made aware of this fact. Not to crush any optimism, but to give realistic expectations, and perhaps to avoid the costs and heartbreak of ‘unexplained infertility’ following ‘successful’ treatment. There is a very fine line between giving encouragement and creating false hope. You may read of success stories, you may hear of women overcoming seemingly astonishing odds, and photos of women beaming with their babies, praising their ‘miracle’ doctors, but make no mistake: these are the faces and stories of less than 50% of women who are diagnosed with IUA and get treatment by the best doctors. But they do not reflect the reality for more than half of women diagnosed with Asherman’s syndrome. The latter are the women who fade into the background, the ones doctors and patients alike would like to forget about, or blame the lack of success on other reasons. Let us not underestimate the significance of the initial trauma underlying the Asherman’s syndrome. Some of us got a worse deal than the others. Worst of all, there is no clear way of predicting whether treatment will be successful or even knowing if it was successful. The only way to know is to try to conceive. If you do have a baby, your treatment was successful. If you don’t, your treatment may not have fully restored your fertility (or you have other causes of unexplained infertility). But let’s not exaggerate the likelihood of the latter- why would someone who was previously capable of getting pregnant suddenly have ‘unexplained infertility’ after having had Asherman’s syndrome? Fibrosis from Asherman’s syndrome can affect blood flow to the endometrium and reduce the chance of implantation or maintaining a pregnancy. I’m not saying one should not seek treatment. By all means, please do whatever is necessary to improve your chances of regaining your fertility! But don’t be too surprised if you don’t end up with a success story.
The attitude of the medical community is also to blame for encouraging the view that treatment is the best answer to the problem. For reasons which evade me, they seem to think it is more logical to subject all women to blind surgery causing Asherman's syndrome in a non-negligible proportion of them, and then to attempt surgical correction and hormonal therapy on those who do develop IUA in the hope that at most 50% of them will have a child (30-40% with moderate to severe IUA, 80% with mild IUA). Not to mention that these future pregnancies are at risk of serious complications, like placenta accreta, preterm delivery, intrauterine growth restriction, cervical incompetence etc. How logical is this? What is the advantage or logic in performing two (or more) expensive, difficult and potentially risky uterine surgeries- one which can cause damage, and one (or more) to repair the damage of the first surgery? Why not nip it at the bud and not cause damage to begin with?
Why not simply use drugs or hysteroscopy to empty the uterus, preventing scarring in the first place? When you consider that there are ways of emptying the uterus without blind surgery (either by using drugs like misoprostol or mifepristone, or visually guided hysteroscopy) the surgical approach makes no sense whatsoever. Is the approach of D&C followed by corrective surgery in the best interest of patients? Absolutely not.
In my next post I will include modern studies on outcomes of treatment as evidence.
Continued in Part II
Some doctors might still have the attitude that anyone whom they cannot treat successfully should give up hope, even if they are not highly skilled or experienced in the treatment of intrauterine adhesions. However, a new and equally detrimental view is being encouraged among sufferers: that treatment has come so far that anyone who is diagnosed stands a very good chance of conceiving and delivering a healthy baby (provided they go to the right doctors). While it’s true that some doctors have much more training, experience and expertise in the treatment of Asherman’s syndrome, the harsh reality is that the overall success rate is not above 50% (and lower for the moderate to severe cases)- even with the best doctors. If anyone tells you that there are doctors who have higher success rates with moderate to severe cases than 50%, they are either not being truthful or simply don’t know (or prefer not to accept) the reality.
It’s a bitter pill to swallow, but women need to be made aware of this fact. Not to crush any optimism, but to give realistic expectations, and perhaps to avoid the costs and heartbreak of ‘unexplained infertility’ following ‘successful’ treatment. There is a very fine line between giving encouragement and creating false hope. You may read of success stories, you may hear of women overcoming seemingly astonishing odds, and photos of women beaming with their babies, praising their ‘miracle’ doctors, but make no mistake: these are the faces and stories of less than 50% of women who are diagnosed with IUA and get treatment by the best doctors. But they do not reflect the reality for more than half of women diagnosed with Asherman’s syndrome. The latter are the women who fade into the background, the ones doctors and patients alike would like to forget about, or blame the lack of success on other reasons. Let us not underestimate the significance of the initial trauma underlying the Asherman’s syndrome. Some of us got a worse deal than the others. Worst of all, there is no clear way of predicting whether treatment will be successful or even knowing if it was successful. The only way to know is to try to conceive. If you do have a baby, your treatment was successful. If you don’t, your treatment may not have fully restored your fertility (or you have other causes of unexplained infertility). But let’s not exaggerate the likelihood of the latter- why would someone who was previously capable of getting pregnant suddenly have ‘unexplained infertility’ after having had Asherman’s syndrome? Fibrosis from Asherman’s syndrome can affect blood flow to the endometrium and reduce the chance of implantation or maintaining a pregnancy. I’m not saying one should not seek treatment. By all means, please do whatever is necessary to improve your chances of regaining your fertility! But don’t be too surprised if you don’t end up with a success story.
The attitude of the medical community is also to blame for encouraging the view that treatment is the best answer to the problem. For reasons which evade me, they seem to think it is more logical to subject all women to blind surgery causing Asherman's syndrome in a non-negligible proportion of them, and then to attempt surgical correction and hormonal therapy on those who do develop IUA in the hope that at most 50% of them will have a child (30-40% with moderate to severe IUA, 80% with mild IUA). Not to mention that these future pregnancies are at risk of serious complications, like placenta accreta, preterm delivery, intrauterine growth restriction, cervical incompetence etc. How logical is this? What is the advantage or logic in performing two (or more) expensive, difficult and potentially risky uterine surgeries- one which can cause damage, and one (or more) to repair the damage of the first surgery? Why not nip it at the bud and not cause damage to begin with?
Why not simply use drugs or hysteroscopy to empty the uterus, preventing scarring in the first place? When you consider that there are ways of emptying the uterus without blind surgery (either by using drugs like misoprostol or mifepristone, or visually guided hysteroscopy) the surgical approach makes no sense whatsoever. Is the approach of D&C followed by corrective surgery in the best interest of patients? Absolutely not.
In my next post I will include modern studies on outcomes of treatment as evidence.
Continued in Part II
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:
-miscarriage
-postpartum retained placenta
-abortion
-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.
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:
-miscarriage
-postpartum retained placenta
-abortion
-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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