What’s going on inside your uterus is not a thought that crosses most of our minds on a daily basis. Sure, we are reminded of that organ every month when “Aunt Flo” arrives, but unless you are a medical student, a gynecologist, or a woman who is having problems getting or holding on to a pregnancy, you are probably not all that aware of your uterus. But news flash…the uterus is a pretty important organ with an essential role in reproduction.
This may come as a surprise, but it is actually a muscle. Yup, that’s why you get those intense monthly cramps—and why Advil and Motrin work so well at taking them down a notch. The uterus’s primary job is to carry a pregnancy. And not to get all science-y or medical, but when you think about how the uterus grows and shrinks, thickens and sheds, and carries and delivers, it’s sort of unbelievable. While its marathon is not 26 miles, it actually can go the distance for you several times in your life (depending on how many pregnancies you have). It goes from the size of an orange to the size of a watermelon, all in matter of nine months. Pretty unbelievable stuff!
So, how can you tell if your muscle is in tiptop shape? Obviously, given its location, you can’t stare at it in the mirror as it flexes! The best indication of how your uterus is functioning is the arrival of your monthly “friend.” For women who are not on hormonal contraception (pills, patch, IUD), you should expect a period about every 30 days. While the regularity of your period is not the focus of this piece, and you shouldn’t call your GYN to report a 27- vs. a 32-day cycle, no period or very minimal/light flow might be evidence that something is off inside your uterine cavity. Changes in the character (heavy vs. light) or content (days) of bleeding can also be the signal to seek help.
The uterine cavity (a.k.a. womb) is composed of two layers: the basalis and the functionalis. Think of the basalis as the bottom or the base and the functionalis as the top, or the functioning layer. Every month, when a woman menstruates, she sheds her functionalis, or functioning part. After its departure, the basalis works to replenish or restock this very important important aisle. When damage occurs, the front-line functionalis is the first to take the hit, and as you can imagine, the more soldiers lost, the worse the situation.
And while the uterus takes losing its front line hard, it takes losing its reserve troops (the basalis) even harder. Damage sustained down to the basalis can cause irreparable harm. If you lose the basalis, then not only do you lose that month’s war, but you will also lose all wars in the future. This is because your body will have no way to regrow what has been lost. So bottom line, varying degrees of insult can have varying degrees of injury. Maybe it really is all about the base…
However, while scar tissue in the uterus can translate into no period, what your uterus does is often a reflection of the message that your ovaries (and actually your brain) are sending its way. That’s why women who don’t produce estrogen for any number of reasons (too much exercise, too little food, or even menopause) don’t get a period. No estrogen = no uterine lining. No uterine lining = no period. The estrogen produced by your ovaries works to thicken the uterine lining (a.k.a. the uterine cavity).
So in many cases, women who are not getting a period have a functioning uterus. If the appropriate hormones are delivered in the appropriate fashion, all systems will be a go. Differentiating between the two and trying to figure out where the roadblock is, is actually fairly easy.
While it does take a visit to your OB/GYN and in some cases a fertility specialist, finding out who “did it” is simpler than a game of Clue. Professor Plum in the study with a candlestick it is not. A good history focusing on previous pregnancies, particularly how they ended D&Cs, abortions, retained placenta, and even a C-Section is of the utmost importance. These are the flashing red lights for who may have scar tissue lingering in their uterus and preventing a future pregnancy from occurring. Asherman’s syndrome is the medical term for this condition.
The uterus can develop scar tissue in response to some sort of an injury. Just like any scrape, cut, or bruise, the more significant the injury that caused it, the more significant the scar. While the injury is most frequently a D&C (dilation and curettage) after a pregnancy (be it a miscarriage, an abortion, or a piece of placenta that remained inside after a delivery), it can result from other causes (i.e. an IUD or an infection).
The degree of scarring can be determined by looking inside the uterus with a variety of imaging tests (ultrasound, hysterosalpingogram , hysteroscopy). It can also be suggested by how light, heavy, or absent your period is. For example, if the scar tissue is severe, it could have damaged most of the uterine cavity; this would cause minimal or no bleeding (medically termed amenorrhea). So while the ovaries are sending all the right signals, the uterus lacks the ability to respond to the message.
Even the most extreme cases of scarring can frequently be fixed. You just need to find a good doctor who has a good idea how to navigate the situation. Uterine scarring requires surgery to remove the adhesions (a.k.a. scar tissue) and restore the cavity (a.k.a. womb) to its original shape. While it can make a major difference in your baby-bearing ability, it is a fairly minor procedure, an outpatient procedure that lasts no more than a couple of hours.
The cervix is dilated to allow the placement of a camera. The camera is connected to a monitor (don’t worry; there will be no broadcasting or streaming!), which allows the surgeon a front-row seat to what is going on inside. After identifying the damaged tissue, instruments are threaded through a channel on the camera. The surgeon’s instrument of choice (we like scissors) is used to remove the scarring. Following the procedure, a tiny catheter is placed into the uterus to keep the uterine walls from touching each other for the next five to seven days. Additionally, while the catheter is camped out in your uterus, you will start about a 21- to 28-day course of estrogen and progesterone. The theory behind this cocktail, catheter, and medications, is to go full force on rebuilding a healthy uterine lining.
So does it work? Can even the most damaged of uteri be remodeled? In most cases, yes….mild and moderate cases of uterine scarring are fairly responsive to treatment. Most women go on to have monthly menses (can’t believe you would ever cheer about that, right?) and conceive. Subsequent pregnancies can be at higher risk for placental implantation problems (placenta previa, accreta), but most go the distance without any issues.
Severe cases can present even the most experienced surgeons with a formidable challenge. While it’s often not the removal of the damaged tissue that keeps the red light red, it’s the uterus’s ability to restore good healthy tissue that keeps things at a halt. If damage was sustained all the way down to the basalis, restoring a functioning cavity can be nearly impossible. In such cases, although recreating a functional cavity may evade even the most gifted surgeons, pregnancy can be achieved with the use of a gestational carrier.
Many things in life happen outside of our control. Even the most type-A of us who fight to plan and control every minute (trust us, we get it!) can’t script how our uterus will react to an insult. However, we can outline a plan of attack if something should seem off. If you feel that something is not right, go speak to your GYN, and leave out no details. We need to have all the facts when it comes to your medical history.
Together, we can come up with a road map to navigate a path through even the roughest of waters. It may take a lot of fight, including a few trips to the operating room and a few rounds of estrogen/progesterone, but ultimately with time, the battle can almost always be won.