Intrauterine Adhesions & Asherman’s Syndrome
Asherman’s syndrome or intrauterine adhesions, is an acquired uterine condition, characterized by formation of adhesions or scar tissue within the uterus. In simple language these are thick bands of scar tissue which make the front and back wall of uterus stick to each other. (To naked eye they look like dried glue bands). The scar tissue may lead to obliteration of the cavity. They may occupy only a part of uterus or the entire cavity. Depending on the extent of adhesions we can classify the syndrome as mild, moderate or severe. These adhesions are generally avascular.
Video of calcification
(Video lateral wall synechiae)
There is a variant of Asherman’s syndrome that is more difficult to manage called as “unstuck Asherman’s” or “endometrial sclerosis”. In this condition the uterine walls are not stuck together, instead the endometrium is peeled off and destroyed.
How do I know that I may have Asherman’s syndrome?
Symptoms depend upon the severity of adhesions , with some women having no symptoms at all. Many a times in such women, Asherman’s syndrome is diagnosed during investigation for infertility or recurrent pregnancy loss. Most women, however present with either decreased blood flow during their menstrual periods or complete amenorrhoea (absence of menstrual flow). Some women experience excessive pain during menstrual periods as uterine muscle have to contract harder to get rid of menstrual fluid past the scar tissue. Sometimes the scar tissue may completely obstruct the menstrual fluid and cause severe pelvic pain.
What causes intrauterine scarring or synechiae?
Normally uterus is lined by endometrium which is shed cyclically in every menstrual cycle. Trauma to this endometrial lining triggers the process of wound healing which leads to formation of scar tissue or adhesions. For example if you get a cut in your skin the two edges will stick to each other and form a scar. Similar process can occur if there is deep cut or trauma to both front and back wall of uterus. When this trauma heals it forms a scar which will finally make both the walls stick to each other.
Pregnancy related dilatation and curettages (D & C’s) account for 90 % of Asherman’s cases. These include D & C performed because of missed or incomplete abortions, elective abortions or after delivery for heavy bleeding in cases of retained products. Asherman’s risk increases with the number of D&Cs performed; after a single procedure the risk is 16% however after 3 or more D&Cs the risk jumps to 32%. Adhesions may also occur following pelvic surgeries such as caesarean section, fibroid removal and septal surgeries. In developing countries like India, infection particularly Tuberculosis and other RTI/ STIs are also an important cause of intra uterine scarring.
What is the incidence of Asherman’s syndrome?
Asherman’s is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as ultrasound scan. The condition is estimated to affect 1.5% of women undergoing HSG, between 5 and 39% of women with recurrent miscarriage, and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion.
What investigations will help in the diagnosis?
Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).
Fig showing Hysterosalpingogram with filling defects suggestive of intrauterine adhesions.
What is the treatment of Asherman’s syndrome?
Asherman’s must be treated by an experienced surgeon via hysteroscopy (sometimes assisted by Laparoscopy). Under direct visualization of hysteroscope the scar tissue is cut with scissors. However one should remember that adhesions have a tendency to reform especially in more severe cases. In order to prevent re-scarring after surgery, estrogen supplementation may be given to stimulate uterine healing and growth of endometrium. A balloon can be placed in the cavity to prevent apposition of the walls during the immediate post-operative healing phase for 1 week. The pre-operative instructions are same as in other hysteroscopic surgeries.