COMMENTARY

What's the Best Way to Prevent Adhesion Formation After Hysteroscopy?

Peter Kovacs, MD, PhD

Disclosures

September 21, 2016

Intrauterine Adhesion Prevention After Hysteroscopy: A Systematic Review and Meta-analysis

Healy MW, Schexnayder B, Connell MT, et al
Am J Obstet Gynecol. 2016;215:267.e7-275.e7

Background

Intrauterine pathology can be best assessed at the time of hysteroscopy. Operative hysteroscopy also allows the physician to treat any pathology he or she finds. Polyps, fibroids, or congenital anomalies can be removed and bleeding abnormalities, for example, can be managed by endometrial ablation.

A side of effect of surgery, however, is that adhesions may develop. Depending on the indication for surgery, technique used, and experience of the operating physician, in up to 80% of cases some degree of adhesion formation can be found postoperatively.[1] Adhesions may lead to further problems, including bleeding anomalies, dysmenorrhea, adverse reproductive outcome, and hematometra.

Prevention of postoperative adhesions is therefore important. This may be accomplished by infusing various substances into the cavity, inserting physical barriers, using medical therapy, or performing second-look hysteroscopy shortly after the initial procedure.

This systematic review and meta-analysis assessed the available evidence regarding these options.

Summary

The systematic review is based on 12 randomized controlled trials (RCTs), and the meta-analysis is based on eight RCTs. Trials that compared various preventive measures and included postoperative hysteroscopy to assess adhesion formation were included. The following findings were reported:

  • Hyaluronic acid gel reduced adhesion formation (10%-18% in the treatment group vs 22%-32% in the control group; relative risk, 0.44; 95% confidence interval, 0.22-0.27).

  • Oral estrogen was not associated with a reduction in postoperative adhesions.

  • The use of human amnion or insertion of a copper intrauterine device (IUD) after operative hysteroscopy as an adhesion barrier was not shown to be effective.

  • Repeat hysteroscopy with estrogen, progesterone, or IUD insertion 1 week after surgery was shown to be more effective at reducing adhesions than estrogen, progesterone, or IUD insertion alone.

The authors pointed out that most of the evidence is based on small RCTs with various methodological problems (eg. lack of blinding). In addition, evidence for the benefit of the two gels comes from one center and has not been reproduced by others. There is therefore a need for further properly designed RCTs to assess various adhesion barriers.

Viewpoint

Abnormal uterine bleeding, dysmenorrhea, congenital anomalies, and adverse reproductive outcome may all require proper evaluation of the uterine cavity. Multiple methods are available (eg, saline sonohysterogram, hysterosalpingogram, MRI), but only hysteroscopy will allow a "see and treat" approach.

At the time of menstruation, the functional layer of the endometrium is shed and the endometrium regenerates from the basal layer.[2] If the basal layer is injured, it could lead to adhesion formation. This risk is especially high if the injury is followed by a period of hypoestrogenism that does not allow proper regeneration.

Any measure that allows enough time for regeneration and healing after the trauma to the basal layer will reduce the chance of adhesion formation. This could involve infusion of various liquids, insertion of physical barriers, or use of hormones to expedite endometrial proliferation.

Despite the wide availability of hysteroscopy, surprisingly few RCTs have evaluated these methods. Ideally, the operating physician would not be the same physician performing the follow-up hysteroscopy. This would allow the physician performing the follow-up to objectively assess adhesion formation.

The RCTs included in this review included surgeries done for various indications (polyp vs septum); by different methods (electrosurgery vs use of scissors); by physicians with different expertise; and, most important, in a small number of patients. The results should be reproduced by several groups to confirm efficacy.

On the basis of the available evidence, it is hard to decide which method to use to prevent postoperative adhesions. Future studies will hopefully be able to give us more guidance.

Abstract

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