Asherman's syndrome

Overview

Asherman's Syndrome, also known as intrauterine adhesions (IUA) or intrauterine synechiae, is a condition characterized by the formation of scar tissue inside the uterus, often leading to partial or complete obstruction of the uterine cavity. This condition can result in menstrual abnormalities, infertility, or recurrent pregnancy loss. It was first described by Dr. Joseph Asherman in the mid-20th century.

Asherman’s Syndrome is most commonly acquired after uterine surgery or trauma, and it can significantly impact reproductive health if not diagnosed and treated early.

Causes

Asherman’s Syndrome typically occurs after damage to the endometrial lining of the uterus, especially the basal layer responsible for regeneration. Common causes include:

• Dilation and curettage (D&C): Especially after miscarriage, abortion, or retained placenta

• Uterine surgery: Including myomectomy or cesarean section

• Radiation therapy to the pelvis

• Pelvic infections: Such as genital tuberculosis (more common in developing countries)

• Intrauterine device (IUD) trauma: Rarely, if improperly inserted

Symptoms

The severity of symptoms depends on the extent of adhesions and whether the uterine cavity is partially or completely obstructed. Common symptoms include:

• Hypomenorrhea: Light or scanty menstrual flow

• Amenorrhea: Complete absence of menstruation

• Infertility or difficulty conceiving

• Recurrent miscarriages

• Pelvic pain or cramping: Especially during periods, due to trapped blood (hematometra)

Diagnosis

Diagnosis of Asherman’s Syndrome involves imaging studies and direct visualization of the uterine cavity:

• Hysteroscopy: Gold standard for diagnosis; allows direct visualization and possible treatment of adhesions

• Hysterosalpingography (HSG): An X-ray test that shows the outline of the uterine cavity and fallopian tubes

• Sonohysterography: Ultrasound with saline infusion to visualize intrauterine structures

• Transvaginal ultrasound: May detect uterine abnormalities or fluid buildup

A thorough medical history, especially related to uterine procedures or miscarriages, also aids diagnosis.

Treatment

The main goal of treatment is to remove adhesions, restore normal uterine anatomy, and improve fertility or menstruation:

Surgical Management:

• Operative hysteroscopy: Adhesions are cut and removed under direct vision using hysteroscopic scissors or electrosurgery

• Adhesion prevention: Intrauterine balloon, stent, or gel barrier may be placed post-surgery to prevent recurrence

Hormonal Therapy:

• Estrogen therapy: Prescribed after surgery to promote endometrial healing and regeneration

Follow-Up Care:

• Repeat hysteroscopy or imaging to assess for re-adhesion

• Monitoring menstrual regularity and fertility status

Prognosis

The prognosis depends on the extent and severity of adhesions:

• Mild to moderate cases: Good outcomes with surgical treatment; normal menstruation and fertility often restored

• Severe cases: May have a higher risk of recurrence or poor endometrial response, impacting fertility

• With proper treatment and follow-up, many women are able to conceive and carry pregnancies to term

Early diagnosis and intervention significantly improve outcomes. Long-term prognosis also depends on any underlying or contributing conditions, such as infections or uterine trauma.