Asherman's syndrome

Question 1

Define Asherman’s syndrome.

Answer 1

Fibrosis and adhesion formation in the endometrial cavity following irreversible damage to the single layer thick basal endometrium.

Question 2

Explain the aetiology of Asherman’s syndrome.

Answer 2

Usually occurs after pregnancy when there has been uterine infection (endometritis). Also occurs after overzealous curettage of the uterine cavity during surgical management of miscarriage or following secondary post-partum haemorrhage.

Question 3

What are the risk factors of Asherman’s syndrome?

Answer 3

Surgery e.g. miscarriage curettage, C-section; insertion of IUD, Schistosomiasis

Question 4

Summarise the epidemiology of Asherman’s syndrome.

Answer 4

Rare

Question 5

Recognise the presenting symptoms of Asherman’s syndrome.

Answer 5

Reduced or absent menstrual shedding

Adhesions in lower uterine tract: severe pelvic pain and retrograde menstruation

Subfertility

Can cause recurrent miscarriage and secondary infertility

Question 6

Recognise the signs of Asherman’s syndrome on physical examination.

Answer 6

Normal
Cannot be diagnosed on bimanual examination

Question 7

Identify appropriate investigations for Asherman’s syndrome and interpret the results.

Answer 7

- Sonohysterography: Saline infusion during ultrasound scan

- Hysterosalpingography: Shows filling defects with homogenous opacity surrounded by sharp edges; high false positive rate; an x-ray examination of a woman’s uterus and fallopian tubes; shows abnormal distorted endometrial cavity with multiple adhesions (reveals extent of the
problem)

- TVUSS: Useful when cervix is obstructed; shows echo dense pattern with difficult visualisation of the endometrium interrupted with one or more cyst like areas; best carried out in luteal phase; not reliable diagnostic tool; shows uterus partially enclosed by corporal adhesions

- MRI: May be helpful as additional diagnostic tool especially when adhesions involve endocervix

- Hysteroscopy (gold standard): Done using a hysteroscope, a thin, lighted tube that is inserted into the vagina to examine the cervix and inside of the uterus; shows distorted cavity by fibrous tissue; fallopian ostia may be occluded.

Question 8

Generate a management plan for Asherman’s syndrome.

Answer 8

Try and prevent by using more conservative methods.

Treatment stages
- Treatment (Dilatation and curettage, hysteroscopy, hysterotomy)
When adhesions are filmy, tip of hysteroscope may be enough to break down adhesions and restore cavity through no touch approach in outpatient setting without general anaesthesia

• Re-adhesion prevention (Intrauterine device, Uterine balloon stent, Foley’s catheter, anti-
  adhesion barriers)
• Post-operative assessment (Repeat surgery; diagnostic hysteroscopy; ultrasound).
  Although the restoration of menses is considered a good marker of success, other diagnostic investigations are fundamental for an exhaustive evaluation.

Question 9

Identify the possible complications of Asherman’s syndrome and its management.

Answer 9

Surgery can be difficult and risks further uterine trauma

Endometrial cancer may be missed due to blocked outflow of postmenopausal bleeding

Pregnancy:

• Miscarriage
• Infertility
• Poor implantation following IVF
• Abnormal placentation: manage as high risk pregnancy

Question 10

Summarise the prognosis for patients with Asherman’s syndrome.

Answer 10

After hysteroscopic surgery, an overall pregnancy rate from 40% to 63% is described

Fertility restoration after hysteroscopic treatment seems to be influenced by several factors such as menstrual pattern before and after the surgery, severity of adhesions and adhesions recurrence rate after treatment.

Reformation of adhesions after surgery is 3.1-23.5%