I spent almost two years being told my test results were normal. Two years of light periods, of cramps that went nowhere, of doctors reassuring me that everything looked fine. It was not fine. What I had was asherman's syndrome — and it was invisible to every test they were ordering.
If you are reading this, you are probably somewhere in that same fog. Your periods have changed. Something feels off. But the tests keep coming back normal, and nobody is connecting the dots. So let me break down exactly how ashermans is diagnosed, which tests actually detect it, which ones miss it entirely, and what you need to say to get the right investigation.
Asherman syndrome involves scar tissue (adhesions) forming inside the uterine cavity — most commonly after a dilation and curettage (D&C), miscarriage management, or uterine surgery. The problem is that standard gynaecological investigations are not designed to look inside the cavity. They look at the uterus from the outside in. Scar tissue sitting inside the uterine walls is, essentially, invisible to many of these tests.
This is how women with ashermans end up with a label of unexplained infertility for years. The infertility is not unexplained at all — the right test just was not done.
According to Mayo Clinic, the three hallmark presentations of Asherman syndrome are infertility, menstrual abnormalities (including very light periods or periods that have stopped), and pelvic pain — and the definitive diagnosis is made via hysteroscopy. Not ultrasound. Not blood tests. Hysteroscopy.
A diagnostic hysteroscopy is the gold standard for diagnosing ashermans syndrome. Full stop. It involves a thin camera being inserted through the cervix into the uterine cavity so your doctor can directly visualise any adhesions, their density, and how much of the cavity they affect.
This is the test I wish I had been offered in year one. It is not a complicated procedure — a diagnostic hysteroscopy is usually done under light sedation or local anaesthetic, often as a day procedure. Most women find it manageable, and the information it provides is irreplaceable.
As Cleveland Clinic confirms, diagnostic hysteroscopy allows your doctor to evaluate the severity of scar tissue and see the full picture of your uterine cavity — something no imaging test can match.
If you have symptoms of asherman's syndrome — especially light periods or periods that have stopped after a uterine procedure — asking specifically for a hysteroscopy is the most important thing you can do.
These are the investigations you are most likely to be offered first. They are not useless — they can provide useful supporting information — but none of them can definitively rule out ashermans.
A transvaginal ultrasound looks at the uterus from the outside using sound waves. It can sometimes show thickening or irregularities in the endometrial lining, but it cannot reliably detect adhesions inside the cavity. My first ultrasound was reported as normal. I had moderate Asherman's.
SIS involves filling the uterine cavity with saline before an ultrasound, which helps expand it and makes adhesions more visible. According to research published in the International Journal of Fertility and Sterility, sonohysterography and HSG both have a sensitivity of around 75% for detecting intrauterine adhesions — meaning they miss roughly one in four cases. Not reliable enough to rule out ashermans.
An HSG uses dye and X-ray to outline the uterine cavity and fallopian tubes. It can suggest the presence of adhesions if it shows filling defects — areas where the dye does not flow smoothly. However, it can both miss adhesions and create false positives. It is often used as a screening step before hysteroscopy, not as a final answer.
Hormone panels, thyroid function, and ovarian reserve tests are all important parts of a fertility workup — but they test hormone levels, not the physical state of the uterine cavity. A woman can have perfect hormonal results and severe ashermans at the same time. Blood tests will not find it.
A thin camera is inserted directly into the uterus, allowing the doctor to see adhesions, assess their density, and determine severity. Both Yale Medicine and Cleveland Clinic confirm this is the definitive diagnostic test. An operative hysteroscopy can also treat the adhesions in the same procedure.
A standard investigation for unexplained infertility typically includes blood tests, an ultrasound, an HSG, and semen analysis. What it almost never includes, at least not in the first round, is a hysteroscopy.
This is the diagnostic gap. A woman can go through years of investigations, including multiple rounds of IVF, without anyone ever looking directly inside her uterine cavity. If she has ashermans — even moderate adhesions — every embryo transfer may fail for a reason nobody has identified.
The research is clear: hysteroscopy before IVF significantly improves outcomes in women with uterine abnormalities. But it is still not standard practice everywhere.
If you have had any of the following, you have a legitimate reason to ask specifically for a hysteroscopy:
You do not need to wait until you have tried everything else. You can ask for a hysteroscopy directly. If your GP or gynaecologist is hesitant, you can ask for a referral to a reproductive endocrinologist or a specialist in uterine cavity assessment.
What to say to your doctor: "I have had [procedure/miscarriage] and since then my periods have changed significantly — they are much lighter and I sometimes have cramping with very little flow. I would like to investigate whether there is any intrauterine scarring. Can we discuss a hysteroscopy?"
A diagnosis of asherman syndrome is not the end of the road — for most women, it is actually the beginning of clarity. An operative hysteroscopy can remove adhesions in the same session or a planned follow-up procedure. After treatment, most women are placed on an estrogen protocol to help the lining recover and reduce the risk of adhesions reforming.
Outcomes depend on the severity of adhesions — mild to moderate cases have the best results, with significant improvements in menstrual flow and fertility. You can read more about what the procedure involves in my article on hysteroscopy for Asherman's: what to expect.
The key message is this: you cannot treat what has not been diagnosed. If something feels wrong — if your light periods started after a procedure, if your period has stopped, if you keep miscarrying, if your infertility is sitting in the "unexplained" basket — the uterine cavity needs to be looked at directly. That means hysteroscopy.
It is worth noting that endometriosis and ashermans can coexist, and endometriosis surgery can itself cause intrauterine adhesions. If you have a known diagnosis of endometriosis and are also experiencing light periods or fertility difficulties, it is worth asking whether intrauterine scarring has been assessed separately — not just pelvic adhesions, but adhesions inside the uterine cavity. These are different structures requiring different investigations.
The Complete Guide includes a full appointment preparation section — the exact language to use, the tests to request, and how to navigate the conversation with your doctor so you leave with answers, not more waiting.
Get the Complete Guide — $97Asherman's syndrome is definitively diagnosed by hysteroscopy — a procedure where a thin camera is inserted into the uterine cavity to directly visualise any scar tissue or adhesions. Supporting tests like saline sonohysterography (SIS) or HSG can suggest the presence of adhesions, but only hysteroscopy provides a conclusive diagnosis and allows assessment of severity.
No. A normal transvaginal ultrasound does not rule out ashermans. Intrauterine adhesions are often not visible on standard ultrasound, particularly when mild or moderate. Many women with confirmed asherman syndrome have had normal ultrasound results before receiving their diagnosis via hysteroscopy.
If you have light periods or your period has stopped after a D&C or other uterine procedure, ask your doctor specifically for a diagnostic hysteroscopy. A saline infusion sonohysterography (SIS) can be a useful first step, but hysteroscopy is the only test that can definitively confirm or rule out ashermans.
Yes. Research shows that HSG misses approximately 25% of intrauterine adhesion cases. While HSG can indicate the presence of adhesions through filling defects, it is not sensitive enough to rule out ashermans. A hysteroscopy is required for definitive diagnosis, particularly if symptoms — such as unexplained infertility or light periods — persist despite a normal HSG.
Medical Disclaimer: This article is written from personal experience and is for informational purposes only. It is not medical advice. Please consult a qualified healthcare professional for diagnosis and treatment. The Asherman's Compass does not provide medical diagnoses.