Ep. 231: Should I worry about Asherman's Syndrome after a D&C or polypectomy? with Dr. Jessica Miller

If you need a uterine surgery, you already have a lot on your mind. Polyps or fibroids need to be removed if you're trying to conceive or you may need a D&C after a pregnancy loss or tough postpartum response. In the midst of this, you're told there's the possibility of developing Asherman's Syndrome. What is this syndrome and how likely are you to develop it? Are there signs to point to whether you have it or ways to reduce your chances of developing it? We talk about all of this and more in our interview with Dr. Jessica Miller, NaProTechnology Medical Consultant and Fellowship Trained Surgeon.

Episode at a glance:

⭐️ What is Asherman's Syndrome?
⭐️ How can Asherman's to develop Asherman's?
⭐️ Are there things that the doctor or patient can do to reduce the chances of developing it?
⭐️ What are the signs you may have it?
⭐️ How can Asherman's be treated?

NOTE:  This does reference pregnancy loss, miscarriage, and D&Cs. 

GUEST BIO: Dr. Jessica Miller is a board-certified OB/GYN and fellowship-trained NaPro surgeon in Billings, MT dedicated to root-cause, restorative women’s health. She integrates surgical expertise with a holistic, evidence-based approach to fertility and gynecologic care. Her work focuses on helping women understand their cycles, address underlying conditions, and achieve optimal reproductive health.

SHOW NOTES:

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Transcript

Caitlin Estes (00:24)

Welcome back to the Woven Well podcast. Today we're going to talk about a condition that doesn't get a ton of coverage, but can be a really scary possibility for any woman facing uterine surgery. And that is Asherman syndrome. So you know how when you go to get your wisdom teeth removed and they tell you there's just a unlikely chance of maybe hitting a nerve in your jaw and you'll never be able to feel your jaw again. No, just me.

 Well, anytime you have some type of surgery, these risks, some big risk it seems, is floated about and it's hard to know how seriously to take them. Well, that certainly applies in a situation like this.

 So I've invited Dr. Jessica Miller, a board certified OB-GYN and fellowship trained NAPRO surgeon dedicated to root cause restorative women's health to share more about Ashermans and what we need to know. Dr. Miller integrates surgical expertise with a holistic evidence-based approach to fertility and gynecological care. Her work focuses on helping women understand their cycles, address underlying conditions and achieve optimal reproductive health. And I'm glad to have her on with us today.

 Dr. Miller, welcome to the show.

 Dr. Miller (01:38)

Hi, thank you so much for having me.

 Caitlin Estes (01:41)

I'm glad to have you here and to talk about this because I hear a lot of concern over the possibility of developing Asherman's syndrome with something like a D&C, but can you explain to us what Asherman's is and how someone actually develops it?

 Dr. Miller (02:00)

Yeah, absolutely. So we think of Asherman syndrome as intrauterine adhesion. So typically this is scar tissue that forms inside the uterus.

 Most commonly, this is caused by some type of trauma to the inside lining of the uterus to the endometrium. So we think of things such as, like you mentioned, D&Cs but also other intrauterine surgeries. So if you had a uterine septum removed, if you had a fibroid that was removed within the uterus, those could also lead to this condition. In particular, we do see a higher risk for the more procedures you would have on the intrauterine lining. And then also in particular, if you have a D&C that's performed in relation to a miscarriage or even postpartum, we see that the endometrium is more prone to damage at that time. So ultimately, I would think of this as some type of abnormal healing that happens after a direct trauma to the endometrial lining.

 Caitlin Estes (02:57)

Hmm. Well, we always hear that it's uncommon, you know, that's what the doctor always says, it's uncommon, but it's still obviously a major fear, especially for those who are actively trying to conceive and want to make sure to preserve that fertility. So how much of a factor would you say that this should be when determining whether or not to get something like a D&C after a pregnancy loss or for some other reason?

 Dr. Miller (03:22)

Yeah, absolutely. So unfortunately, it kind of comes down to a case by case basis. for example, not every miscarriage needs a D&C And so that would be a conversation with your physician about just watching and waiting, doing medical management, trying to avoid that D&C if possible. However, there are other situations, whether that's a miscarriage or sometimes postpartum, where it could be a situation that is even life threatening to the patient. And so in cases like that, the risk benefit ratio really tends towards doing the D&C for the safety of the patient. every time it comes down to what is the patient situation, what's the risk, what's the benefit of the procedure. For example, you know, we worry about Ashton syndrome affecting fertility, affecting your ability to carry a pregnancy and not have a miscarriage, but we also worry about fibroids and polyps having those same issues. in that situation, it might be worth going forward removing those polyps and fibroids because the risk is there from a different perspective. So it comes down to a case by case basis.

 Overall, when you look at the general population, the incidence is lower. So for our infertility patients, some numbers estimate like one, one and a half percent of those women will have Asherman syndrome. However, the number really does increase based on your risk factors. So if you're a woman who's had D&Cs, who's had multiple uterine surgeries, your risk is going to be higher. So sometimes we see numbers as high as like 13 % after like a first trimester D&C. It kind of just depends. The numbers are a little bit variable. And then we see those numbers go up if you've had like a fibroid removed, a hystroscopic myomectomy, that type of thing, or again multiple procedures.

 Caitlin Estes (05:09)

That's so helpful to know and I really appreciate how you walked through how you make that decision and yes, there is a risk of it but it may still be worth it to do because one is a possibility versus the other such as fibroids or polyps is a sure thing that we know needs to be removed and that's where I would think it comes down to having a physician who you know and trust and respect to guide you through that, and not just automatically go to a D&C, but really talk through your options, talk through why you may want to consider it and what your risks could be, and if you may be at an increased risk for it. So after you have the procedure, whatever that may be, are there ways to know if you've developed it or not? Like how does one figure out that they have developed Asherman's?

 Dr. Miller (06:00)

Yeah, absolutely. So some patients are completely asymptomatic. So you may be someone who doesn't have symptoms at all.

 But if you are symptomatic, you might notice a complete absence of periods. So you might not have any periods at all if your scar tissue is really severe. You might notice just a decrease in just lighter periods. Other signs would be cyclic pain. So you're having pretty significant pain with your periods or infertility, recurrent miscarriage could cause this as well. But the one big telltale sign is gonna be that if you are symptomatic, it was immediately after some type of uterine trauma. It's going to be a change from prior. And really, even if you are asymptomatic for all of our patients undergoing an infertility workup, we look directly at the endometrium and assess that until you should be assessed for that as part of an infertility workup for sure.

 Caitlin Estes (06:53)

Mm-hmm.

 Okay, that's helpful too. And I would just say anyone who's listening who charts with the Creighton model system, that would be something that would show up on a chart. We often encourage you to write down when you've had some sort of a procedure and if all of a sudden you're going from heavy or moderate days of bleeding to only light or very light days of bleeding and we're not seeing the same kind of period that you had in the past, that could be a sign. So Creighton can be used to help you figure that out and determine if that be something to look into. So how do you actually get it diagnosed? You know, are there good ways like effective ways I should say to get it diagnosed and then ways that aren't actually going to be helpful at all. I think about endometriosis a lot and how they'll say, we'll do an ultrasound, but an ultrasound cannot actually tell you if you have endometriosis. So what works to help diagnose Ashermans?

 Dr. Miller (07:46)

Yeah, absolutely. So what does not work is we can't rule it out based on a physical exam. We can't rule it out based on a pelvic ultrasound. Sometimes the pelvic ultrasound might have some slight abnormalities that might increase our suspicion, but it's unlikely to really give us a diagnosis. And so if you are, for example, undergoing an infertility workup and those are the only things that are performed, we really can't rule it out based on that.

 Additional imaging that has a higher likelihood of increasing our suspicion, but again is not the best diagnostic tool, would include imaging such as a saline infusion sonogram. So where we inject saline into uterus and we expand it. And sometimes you can see some abnormalities on that that would increase your suspicion, especially if the patient has a history that puts them at higher risk. And then an HSG, which a lot of infertility patients are familiar with, a hysterical pingogram again putting dye into the uterus to look at the inside lining as well as the tuple patency in that case, but that can have some abnormalities that might increase our suspicion. However, the ultimate way to diagnose this is going to be hysteroscopy. So hysteroscopy is placing a camera through the vagina into the cervix and directly visualizing the inside of the uterus. So that is the gold standard will definitively tell us based on direct visual

 Do we see any scar tissue? It helps us assess how severe it is. Is there just a little bit? Is it filmy adhesions or is there a lot and it's very dense adhesion? So not only does it allow us a definitive diagnosis, but it gives us more information about it and then you can treat it at the same time.

 Caitlin Estes (09:26)

What would that treatment look like? How do you actually take care of it?

 Dr. Miller (09:30)

Yeah, so we just take out those adhesions. So once you put in the hysteroscope and you visualize those adhesions, typically we use scissors to meticulously excise those adhesions and really reconstruct the uterine cavity to look normal and to look as it should before those adhesions formed and hopefully allow the endometrium to regain normal function once those are gone.

 Caitlin Estes (09:56)

Okay. And is there an increased risk of getting it again from that procedure? Like I'm imagining if someone has had a D&C and then they develop it and you go in and remove all of the scar tissue, could it just come right back?

 Dr. Miller (10:13)

Yeah, unfortunately, we do worry about those patients reforming those adhesions. So their body already responded once to that trauma in a way that was an abnormal healing process. And so they are at risk for that happening again.

 Some of that risk is based on how severe it is. So if they have some thin filmy adhesions, not a lot, that risk will be lower. If they have really dense thick adhesions, most of the cavity is involved, their risk is going to be higher. The way that we try to minimize that recurrence is first and foremost, throughout meticulous surgical process. So really being intentional about how we're excising those adhesions and excising them in their entirety. Some patients might need multiple steps to that process. So you might be a patient, you know, based on a conversation with your physician who needs another hysteroscope down the road and that might even just be a couple weeks to a month later to reevaluate and see what's going on. So it might be a multiple step process to ensure that the cavity is returned to normal. And then we have some other options too that have mixed data about them. So for example, some physicians choose to use estrogen after the procedure and that is thought to stimulate the endometrium, support the endometrium in a positive way that hopefully reduces those adhesions from forming. And then some physicians also use barrier methods such as like a mechanical, like a type of balloon that you would place in the cavity to keep it expanded and to keep it from having contact with the other side of the cavity so you decrease the risk of those adhesions forming that way. So there are a couple of options to work on that and again it depends on the severity but we do really worry that.

 Once it happens, you would have a higher risk of it happening again. So it does need close follow-up.

 Caitlin Estes (12:03)

So does it matter what type of surgeon a woman goes to for that kind of care? You know we talk a lot about working with someone who is trained on preserving fertility and truly treating as much as possible. Is that the same for Ashermans or can any OBGYN do it in the same way?

 Dr. Miller (12:24)

Yeah, most ob-joyans are very familiar with hystroscopic surgery and so most would be able to perform this. I think, like you had mentioned earlier, just having a physician that you really trust and that you feel like you have a good relationship with. And then also you can always ask them how comfortable they feel with this, how often they've treated it. But most general ob-joyans are really familiar with this type of surgical technique.

 Caitlin Estes (12:47)

That's fantastic news, by the way. We are very appreciative of our expert surgeons, but sometimes it can be challenging to find one. And so knowing that you can go to a local OBGYN and they should have the training to do this is, I'm sure, a sigh of relief to many women. that's good. So from the patient side.

 Are there things that we could do to possibly reduce the chance of getting Ashermans or having it come back again? Like is there anything on our end that could improve our chances there?

 Dr. Miller (13:21)

Unfortunately, there's not. really comes down to your risk factors to begin with. So like I mentioned, this is miscarriage D&C or postpartum D&C. There are certain risks surrounding when or how the D&C is performed that would increase the likelihood of Asherman's And then a lot of it comes down to surgeon technique and those options to try to reduce recurrence from the surgeon's side, but unfortunately as a patient, it really just comes down to how your body heals, and there's really, there's not too much that can be done from that perspective.

 Caitlin Estes (13:52)

Okay, well that's good to know at least, you we don't put too much pressure on our own shoulders when it's a situation where there's not much we can do to change the outcome. So now obviously if a woman were trying to conceive, then I could understand why she would immediately want to get this treated in hopes of being able to successfully conceive. But if a woman is no longer trying to conceive, are there still benefits for having the Ashermans removed?

 Would she notice any benefit from that?

 Dr. Miller (14:21)

Yeah, so if you are someone who's asymptomatic, you may not notice benefit. If you have symptoms, this treatment should improve those symptoms, particularly if you're someone who's experiencing cyclic pain secondary to those adhesions, this would be something that you would get treated then. Of note, even if you're not actively trying to conceive or even if you're not struggling with fertility,

 For a patient who is not actively avoiding pregnancy, would also suggest getting this treated because it can be associated with adverse pregnancy outcomes. this is something that if you were to get pregnant, you would have a higher risk of miscarriage or even if you were able to successfully carry that pregnancy, it's associated with things such as preterm birth, low birth weight, abnormal placental implantation, which can be very dangerous. So

 Even if you're not an infertility patient or actively trying to conceive, if you're somebody who has the potential for that, this would be something you would still want to address.

 Caitlin Estes (15:17)

Yeah, very helpful. I really appreciate you talking with us about all this and giving us helpful information to empower us, you know, to look into our own care and what we can do, especially when it comes to something that feels so mysterious. You just don't hear a lot of information about Asherman. So thank you so much for being on and for clarifying it for us.

 Dr. Miller (15:39)

Absolutely, thanks for having me.

 Caitlin Estes (15:42)

Listeners, we get it. It is tough to know how to make the right decision when it comes to your health and future fertility. And so we're here to do whatever we can to support you along the way. Whether it's a free resource on our website or fertility education to help you advocate for your care or a referral to a physician who approaches your health from a restorative approach. We want to do all that we can to support you.

 We'd love for you to join us at our next introductory session or reach out about future resources that you'd like to see right here on the podcast. We always love to hear from you. As always, thanks for listening as we continue to explore together what it means to be Woven Well.