Endometriosis (endo) is a health condition that can cause thick endometrial scarring that leads to adhesions. However, other conditions such as previous surgeries, endometrial ablation (a procedure that destroys tissue), pregnancy, and Asherman’s syndrome can also cause scarring.
This article reviews endometrial scarring and adhesions, what they are, how they occur, symptoms, diagnosis, and treatment.
What Is Endometrial (Uterine) Scarring?
The endometrial lining is the mucus membrane that lines the uterus or womb. This lining thickens during your menstrual cycle to prepare for a possible pregnancy. If pregnancy does not occur, part of the endometrial lining sheds. This is when menstrual bleeding or a period occurs.
Damage to the endometrial lining can cause scar tissue. This can lead to adhesions that cause structures that are usually separated to adhere, or stick together. This includes structures in the pelvis (between the hips) or the front and back walls of the uterus.
While endometriosis is the most common cause of adhesions for those assigned female at birth, they can also result from other things such as pregnancy, surgery, and endometrial ablation.
From Endometriosis or Laparoscopy
Endometriosis occurs when endometrial tissue or implants are displaced outside of the uterus. Tissue can build up on the ovaries, fallopian tubes, or other structures in the pelvis.
Endometrial implants still respond to the hormones that drive your menstrual cycle. They grow and bleed, causing inflammation, pain, and scar tissue.
Previous surgical procedures, including laparoscopic surgery, can lead to clumps of thick scar tissue, causing adhesions. A laparoscope is a surgical instrument with a thin tube and a camera. It is inserted into the abdomen through a small incision during laparoscopic surgery.
Gynecologic Symptoms
The most common symptom of endometriosis is chronic, achy, or crampy pelvic pain. In fact, 90% of those with endometriosis have chronic pelvic pain.
Adhesions cause a different type of pain, often described as a stabbing, tugging, or pulling pain that comes and goes in different positions.
Adhesions can also cause:
Menstrual (period) abnormalities Excessive menstrual cramping Pain during or after sexual intercourse Painful urination, especially during menstrual bleeding Painful bowel movements, especially during menstrual bleeding Infertility (not able to get pregnant) Abdominal bloating Nausea, constipation, or diarrhea
Role of Inflammation
Scar tissue forms in response to injury and inflammation. With endometriosis, the implant bleeds into the surrounding area. This causes an inflammatory reaction that leads to scarring and adhesions. Almost 38% of those with endometriosis have adhesions.
Associated Causes and Conditions
Several health conditions can lead to endometrial scarring, including:
Endometriosis Pelvic inflammatory disease (PID) Severe infection, such as untreated sexually transmitted infections (STIs), diverticulitis (inflammation in a pocket within the small or large intestine), and appendicitis Injury, trauma, or radiation treatment Previous surgery Adenomyosis (when endometrial lining spreads to the muscular wall of the uterus) Autoimmune disorders
Health conditions that can lead to symptoms similar to endometrial scarring include:
Asherman’s syndrome (intrauterine adhesions) Myoma (uterine fibroid) Dysmenorrhea (severe menstrual cramping) Mittelschmerz (pain during ovulation) Ovarian, uterine, or endometrial cancer Ovarian cysts Polycystic ovary syndrome (PCOS)
Effect on Fertility
Endometrial adhesions can cause infertility, making it more challenging to get pregnant. Some people don’t find out they have endometriosis until they see their healthcare provider regarding infertility.
Symptoms of Asherman’s syndrome include:
Menstrual cycle changes Infertility Pregnancy complications Recurrent miscarriage
While the “how” is not entirely understood, several theories exist. Adhesions may block the fallopian tubes, preventing the egg and sperm from meeting. Another theory is that adhesions interfere with ovulation or cause undesirable conditions in the uterus that don’t support the implantation of a fertilized egg.
Diagnosis
Diagnosis begins with a medical history and physical exam, including a pelvic exam and imaging tests such as an ultrasound, computed tomography (CT scan), and magnetic resonance imaging (MRI).
Healthcare providers make a definitive diagnosis through surgery and sometimes a biopsy (removing a sample of tissue for testing in a lab) of the suspicious tissue. However, surgery is typically for treatment rather than for diagnosis alone.
It can take years before someone receives a diagnosis because endometriosis or adhesions can be mistaken for other conditions that cause chronic pelvic pain. These include:
Irritable bowel syndrome (IBS) Interstitial cystitis (IC) (painful bladder syndrome) Pelvic inflammatory disease (PID)
Contact your healthcare provider if you have any of the following criteria:
You have unresolved chronic pelvic pain. You are younger than 35 and have been trying to get pregnant for 12 months or longer. You are over age 35 and have been trying to get pregnant for six months or longer.
Treatment for Adhesions and Scarring
Endometriosis and endometrial scarring are complex, and symptoms vary, making them difficult to diagnose and treat. Early diagnosis and treatment are essential to prevent irreversible damage, especially to the reproductive system and nerves.
Treatment depends on the underlying cause, your overall health, your medical history, the severity of the adhesions, your fertility concerns, and your symptoms. Look for a healthcare provider who listens to you, shows you respect, takes your symptoms seriously, and explains options for your treatment plan.
Pain Control
Mild adhesions may only require observation and pain control, including nonsteroidal anti-inflammatory drugs (NSAIDs), warm baths, or heating pads.
For mild symptoms, you can also try the following options at home:
Tylenol (acetaminophen) Advil, Motrin (ibuprofen), an NSAID Aleve (naproxen), an NSAID
Apply heat using a patch, heating pad, warm bath, or hot water bottle. Use an ice pack or cool cloth (apply to the painful or inflamed area for 15 minutes several times daily). Apply topical medications (on the skin), including pain-relieving patches, gels, or creams. Use Boiron or Naturopathica (arnica) cream or pellets. Try changing positions to see if it takes the pressure off of the nerve. Practice movement or exercise such as swimming.
Medications
Moderate cases may require hormone therapy, fertility medications, or other prescription medications to treat the underlying cause or control inflammation and pain.
Surgery
Severe adhesions may require a hysteroscopy, in which the surgeon cuts out scar tissue or adhesions. Successful removal may require various surgical specialties and multiple surgeries.
Depending on the severity and location of endometrial tissue, scarring, or adhesions, surgery may require surgeons who specialize in:
However, this would be an extreme measure for those who still wish to become pregnant. If the ovaries are removed during a hysterectomy, it causes surgical menopause, which comes with other symptoms.
Gynecology Neurosurgery Orthopedics Colorectal surgery Urology (urinary system)
Many teams also involve a radiology provider to give detailed information about where the adhesions are located and help them plan the best way to remove them. Your team may also include pain specialists, physical therapists, and psychologists.
Fertility Treatment
If adhesions prevent you from getting pregnant, your healthcare provider may suggest surgery or fertility treatments, depending on your age.
An endometriosis specialist has a high level of experience and training. They can refer you to a fertility specialist, endocrinologist, or another surgical specialist if needed.
Minimizing Risk of Recurrence
Endometrial tissue, scars, or adhesions can return even with successful surgery. Healthcare providers may use multiple types of treatment in addition to surgery to help prevent a recurrence.
Sometimes hormone therapy can prevent endometrial tissue from being stimulated by hormones. Not only does this help decrease symptoms, but it can also reduce the inflammation that may lead to scarring.
Healthcare providers may also recommend pelvic floor therapy or a specialist such as a gastroenterologist to prevent complications and recurrence.
Summary
Trauma and inflammation of the endometrium (lining of the uterus or womb) can cause endometrial scarring. For those assigned female at birth, endometriosis is the leading cause of scarring that leads to endometrial adhesions.
Eat a balanced diet (an anti-inflammatory diet is a good choice if you have endometriosis). Limit caffeine. Avoid large amounts of alcohol. Avoid dehydration. Practice stress reduction techniques. Practice STI prevention measures. Consider probiotics (decrease the risk of bacterial vaginosis and yeast infections).
Exercise is also essential for uterine health. It strengthens the muscles around the uterus, increases circulation, decreases body fat (which reduces the amount of excess estrogen), and decreases stress.
Other conditions, such as previous surgeries, endometrial ablation, pregnancy, and Asherman’s syndrome, can also cause scarring and adhesions. Endometrial scarring can cause pain, menstrual abnormalities, infertility, and more.
Diagnosis starts with a medical history and exam but may involve an ultrasound or MRI. A diagnosis is confirmed with surgery and, possibly, a biopsy.
Treatment may involve observation, pain control, medications, or surgery. Depending on the situation, it may also include hormone or fertility treatment.
