Intrauterine Adhesions

Jay M. Berman, M.D., F.A.C.O.G.

Disclosures

Semin Reprod Med. 2008;26(4):349-355. 

In This Article

Abstract and Introduction

Joseph Asherman first described intrauterine adhesions in 1948. It is commonly referred to as Asherman's syndrome and intrauterine synechiae. It is characterized by a spectrum ranging from amenorrhea to menstrual disturbance to normal menses. It is frequently associated with infertility. The true incidence is unknown. Most cases occur within close temporal proximity to a pregnancy, usually within 4 months and usually while the woman is in a hypoestrogenized state. Most cases are associated with trauma to the endometrium from surgical procedures, primarily curettage. Increasingly, cases are associated with myomectomy both abdominal and hysteroscopic, removal of septae, and any other intrauterine surgery. Pathology shows fibrous connective tissue bands with or without glandular tissue, although this may range from filmy to dense.

The diagnosis is primarily by history and a high index of suspicion. Confirmatory tests are increasingly saline infusion hysterography (SIS) or hysterosalpingogram (HSG), although magnetic resonance imaging has also been used. Ultimately, hysteroscopy is employed for the final diagnosis and treatment. Hysteroscopic lysis of adhesions is the main method of treatment. Dense scar tissue and difficult entry into the cervix may require laparoscopic or ultrasound guidance. Most authors use an intrauterine stent and follow treatment with sequential estrogen and progesterone therapy. Increasingly early intervention either with repeat SIS or HSG or most recently with flexible hysteroscopy has been advocated.

Treatments outcomes are difficult to assess as there are no universally agreed upon classification system. However, intrauterine pregnancies rates range from 22 to 45% and live births range from 28 to 32%. The risk of complications for those that achieve pregnancy is significant with a significant risk for placenta accreta and subsequent blood loss, transfusion, and hysterectomy. Prospective controlled studies are needed to determine the best diagnostic and treatments for intrauterine adhesions.

The condition we now commonly refer to as Asherman's syndrome has been called uterine atresia, amenorrhea traumatica, and endometrial sclerosis.[1] This condition has also been referred to as intrauterine adhesions (IUAs) and intrauterine synechiae (IUS). The true incidence is unknown but is likely more common than previously expected. In one series, Dmowski and Greenblatt[2] found an incidence of 1.55% of women subjected to hysteroscopy.

Joseph G. Asherman first described 29 cases of "amenorrhea traumatica (atretica)" in the Journal of Obstetrics and Gynecology of the British Empire (now BJOG) in 1948.[3] These 29 cases describe a complete obliteration of the endometrial cavity. Amenorrhea ranged from 3 months to 12 years. Eleven of the 29 patients previously had a postpartum hemorrhage, 15 a spontaneous abortion, two a procured (termination) abortion, and one a hydatidiform mole. He also states that therapy for this condition should be surgical not hormonal. Sounding and dilatation of the cervix were the only methods used, and he reported only one perforation. Subsequently, 12 of 29 had normal menstruation, and nine of 29 had hypomenorrhea.[3] All together, it was a remarkable case series for 1948.

Indeed, the article further describes the pregnancy outcomes in 10 cases in 3 years. Two were ongoing, three missed abortion, and one intrauterine fetal demise (IUFD) at 8 months. One normal birth required manual removal of the placenta, and one required cesarean section. In all, a record not unlike our current problems with what has become known as Asherman's syndrome. At the conclusion of the article, he makes reference to several articles and abstracts also addressing this as a series of case reports, although he and Stamer disagreed as to the mechanism.[3] Asherman makes reference to Stamer's statement that the "menstrual flow continues undisturbed behind the blockage" leading to hematometra. He notes that none of Stamer's cases had hematometria.[3] Asherman notes that this condition was reported by Fritsch and others from 1894 to 1933 and that Stamer added 24 of his own cases to the total in 1946.[3]

In 1950, Asherman followed his original article with a description of "traumatic intrauterine adhesions." He calls this "regional obliteration of the uterine cavity," and he describes it as due the "partial conglutination" of the uterine walls. In amenorrhea traumatica, the cervix and internal os are involved, whereas in intrauterine adhesions it is the endometrial walls. This required the use of x-rays, which show the filling defects. This paper is accompanied by beautifully reproduced hysterosalpingograms of filling defects. Asherman also describes the difficulty of distinguishing polyps, septa, and submucous fibroids. Again, treatment is described as surgical and unlike amenorrhea traumatica, best done at hysterotomy with the finger. He does describe the use of a catheter passed from above into the vagina and removed in 3 days. He noted that the vaginal approach can also be performed but there is risk of perforation. Asherman addresses what was a very difficult problem by suggesting that a strip of gauze saturated with penicillin be left in place for 1 to 2 days. He suggests that with this prophylaxis, it may be possible to eradicate adhesions completely, in contrast with re-formation of the intrauterine adhesions after lysis. In a remarkable prescient statement, he wonders if the operation can be performed by means of hysteroscopy, a possibility still to be investigated in 1950.[4] Together, these two conditions described by Asherman comprise the clinical spectrum of what is now usually referred to as Asherman's syndrome.[3,4] Most of the initial cases were associated with spontaneous abortion, puerperal hemorrhage treated with curettage, and induced abortion. Additionally, infectious causes of Asherman's syndrome have been attributed to schistosomiasis[5] and tuberculosis.[6] Depending on the location, these organisms may play an important role in the etiology of intrauterine synechiae, however they do not appear to be common etiologic agents for most patients in the United States. In addition to pregnancy-related trauma, intrauterine surgery has become more important as a cause of this condition.

The true incidence of Asherman's syndrome is unknown as the clinical spectrum ranges from amenorrhea to menstrual disturbance to infertility. The American Society for Reproductive Medicine (ASRM) Practice Committee educational bulletin published in 2006 estimates a frequency of 7% of secondary amenorrhea.[7]

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