Asherman's syndrome

Uterine_Fibroids

Asherman's Syndrome (AS), also known as intrauterine adhesions (IUA) or intrauterine synechiae, is an acquired uterine condition characterized by the formation of scar tissue within the uterine cavity. This scar tissue can lead to the walls of the uterus sticking together, resulting in various menstrual irregularities, infertility, and pregnancy complications.

Hysteroscopy of Asherman's Syndrome

HSG view. Note: not the same uterus as in ultrasound or hysteroscopic view; this uterus appears to be T-shaped.

History

The condition was first described by Heinrich Fritsch in 1894 and later extensively characterized by Israeli gynecologist Joseph Asherman in 1948. It is also referred to as Fritsch-Asherman Syndrome in recognition of both contributors.

Hysteroscopic view.

amniotic sheet on ultrasound

Causes

Asherman's Syndrome typically arises from trauma to the basal layer of the endometrium, the inner lining of the uterus. Common causes include:

• Dilation and Curettage (D&C): Procedures performed after miscarriages, childbirth, or elective abortions can damage the endometrial lining, leading to scar formation.

• Pelvic Surgeries: Surgeries such as cesarean sections or myomectomies (removal of fibroids) can result in intrauterine adhesions.

• Infections: Severe pelvic infections, including genital tuberculosis, can cause significant scarring within the uterus.

• Radiation Therapy: Pelvic irradiation for cancer treatment may lead to endometrial damage and subsequent adhesion formation.

Symptoms

The clinical presentation of Asherman's Syndrome varies depending on the extent and location of the adhesions. Common symptoms include:

• Menstrual Irregularities: These can range from reduced menstrual flow (hypomenorrhea) to complete absence of menstruation (amenorrhea).

• Infertility: Adhesions can interfere with implantation or block the passage of sperm, leading to difficulties in conceiving.

• Recurrent Miscarriages: Scar tissue may compromise the uterine environment, increasing the risk of pregnancy loss.

• Pelvic Pain: Some women may experience discomfort or pain, especially during menstruation or sexual intercourse.

Diagnosis

Accurate diagnosis is crucial for effective management. Diagnostic methods include:

• Hysteroscopy: This is the gold standard for diagnosing Asherman's Syndrome. It involves inserting a thin, lighted device into the uterus to directly visualize and assess the extent of adhesions.

• Hysterosalpingography (HSG): An X-ray procedure where contrast dye is injected into the uterus and fallopian tubes to detect filling defects indicative of adhesions.

• Sonohysterography: An ultrasound technique that uses saline infusion to outline the uterine cavity, helping to identify irregularities.

• Transvaginal Ultrasound: While less specific, it can provide initial clues, especially when combined with other imaging modalities.

Classification

Several classification systems have been developed to categorize the severity of Asherman's Syndrome based on factors such as the extent of adhesions and menstrual patterns. These classifications aid in predicting treatment outcomes and guiding management strategies.

Treatment

The primary goal of treatment is to restore the normal anatomy and function of the uterine cavity. Treatment options include:

• Surgical Adhesiolysis: Hysteroscopic surgery is performed to cut and remove adhesions, restoring the uterine cavity's normal structure.

• Post-Surgical Measures: To prevent reformation of adhesions, methods such as the insertion of intrauterine devices (IUDs), application of barrier gels, or estrogen therapy may be employed to promote healing of the endometrial lining.

• Hormonal Therapy: Estrogen therapy is often prescribed post-surgery to stimulate endometrial regeneration and prevent the walls of the uterus from sticking together during the healing process.

Prognosis

The success of treatment largely depends on the severity of the adhesions and the promptness of intervention. Mild to moderate cases often have favorable outcomes with restored menstrual function and the potential for successful pregnancies. Severe cases, especially those with extensive scarring, may have a guarded prognosis, and fertility may remain compromised.

Prevention

Preventative strategies focus on minimizing uterine trauma and include:

• Gentle Surgical Techniques: Utilizing careful and minimally invasive methods during uterine surgeries to reduce endometrial damage.

• Prompt Treatment of Infections: Early and effective management of pelvic infections to prevent the development of scar tissue.

• Alternative Management of Miscarriages: Considering medical management or expectant management of miscarriages when appropriate, to reduce the need for surgical interventions like D&C.

Epidemiology

The exact prevalence of Asherman's Syndrome is challenging to determine due to underdiagnosis. However, it is estimated that up to 25% of women who undergo D&C after a miscarriage or delivery may develop intrauterine adhesions. The risk increases with the number of uterine surgeries performed.

Complications

If left untreated, Asherman's Syndrome can lead to several complications:

• Chronic Pelvic Pain: Ongoing discomfort due to trapped blood or menstrual debris.

• Endometriosis: Retrograde menstruation caused by blocked menstrual flow can lead to the development of endometrial tissue outside the uterus.

• Obstetric Complications: Increased risks during pregnancy, such as abnormal placentation (e.g., placenta accreta), preterm labor, and uterine rupture.

Research and Future Directions

Ongoing research aims to improve the understanding and management of Asherman's Syndrome. Areas of interest include:

• Stem Cell Therapy: Investigating the potential of stem cells to regenerate damaged endometrial tissue.

• Novel Surgical Techniques: Developing advanced minimally invasive procedures to reduce the risk of adhesion formation.

• Biomaterials: Exploring the use of new barrier materials to prevent adhesion reformation after surgery.

See Also

• Endometrial ablation
• Hysteroscopic surgery
• Uterine synechiae
• Fertility preservation
• Reproductive surgery
• Menstrual disorders
• Pelvic Inflammatory Disease
• Gynecological imaging
• Minimally invasive gynecology
• Women's health

External Links

• Asherman's Syndrome Support Group
• The American College of Obstetricians and Gynecologists
• Royal College of Obstetricians and Gynaecologists
• World Health Organization - Women's Health
• Endometriosis Foundation of America

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