Asherman's Syndrome

Question 1

Definition

Answer 1

Adhesions (AKA synchiae) form within the uterus, following damage to the uterus

Question 2

Aetiology

Answer 2

• Uterine curettage: Usually occurs after pregnancy related dilatation and curettage procedure, e.g. in the treatment of retained products of conception (removing placental tissue left behind after birth)
• Intracavity uterine surgery (myomectomy)
• Several pelvic infections (e.g. endometritis)
• Genital tuberculosis

Question 3

Pathophysiology

Answer 3

The endometrium has two layers the superficial functionalis layer and the deeper basalis layer. It is the deeper layer which is responsible for endometrial regeneration once the superficial layer is shed off during menses.
Endometrial curettage (scraping) can damage the basal later of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected.
There may be adhesions binding the uterus walls together or within the endocervix, sealing it shut.
These adhesions form physical obstructions and distort the pelvic organs, resulting in menstruation abnormalities, infertility and recurrent miscarriages.

Question 4

Asymptomatic adhesions

Answer 4

Adhesions may be found incidentally during hysteroscopy. ASx adhesions are not classified as Asherman’s syndrome.

Question 5

Clinical presentation

Answer 5

Typically presents after recent dilatation and curettage, uterine surgery or endometritis with:
- Secondary amenorrhoea (absent periods)
- Significant lighter periods
- Dysmenorrhoea (painful periods)
- May also present with infertility

Question 6

Diagnosis

Answer 6

• FIRST LINE = USS imaging = thin irregular endometial stripe
• GOLD STANDARD = Hysteroscopy = involves dissection + Tx of adhesions
• Hysterosalpingography, = contrast injected into uterus + X-rayed = shows filling defect
• Sonohysterography = uterus is filled with fluid for pelvic USS
• MRI scan

Question 7

Treatment

Answer 7

Dissecting the adhesions during hysteroscopy = hysteroscopic adhesiolysis
- Reoccurrence of the adhesions after treatment is common
To prevent reoccurrence of adhesions a post operative intrauterine balloon catheter for approx -10 days alongside antibiotics to prevent infection
- Exogenous oestrogen treatment is also given for 4 weeks post op.