Asherman's Syndrome

Question 1

Definition

Answer 1

Presence of intrauterine adhesions that may partially or completely occlude the uterine cavity

Trauma, infection causing damage to the basal layer of the endometrium → fibrosis and adhesion formation

• This results in reduced or absent menstrual shedding

Unknown epidemiology but occurs in 5-40% of D&C (dilation and curettage) after miscarriages

Question 2

Aetiology

Answer 2

Infection:

• Infection: This can occur after pregnancy if there has been a bacterial uterine infection (endometritis)
• Endometriosis

Trauma:

• Following secondary PPH (post-partum haemorrhage)
• Evacuating the retained products of conception (ERPC)
• Endometrial resection
• D&C (dilation and curettage) for miscarriage or TOP
• Surgery – myomectomy, C section

Question 3

Symptoms and Signs

Answer 3

Symptoms:

Hypomenorrhoea

• Amenorrhoea
• Menstrual irregularities
• Recurrent miscarriages
• Cyclical abdo pain
• (Past surgical history)

Often no external physical signs

NOTE: intrauterine adhesions are not usually associated with chronic pain except in the case of obstruction occurring at the internal os which may lead to haematometra (menstrual blood accumulating behind the obstructed internal os)

Question 4

Investigations

Answer 4

1st INVESTIGATION- Sonohysterography or hysterosalpingography (HSG)

• May see abnormal distorted endometrial cavity with multiple adhesions

Sonohysterography (SHG) or saline infusions sonography (SIS) METHOD: TVUSS + insertion of soft catheter transcervically with sterile saline injected. Inflate a balloon (similar to a catheter- to prevent leakage of the saline). Findings: sub-endothelial linear striations + ‘boggy’ uterus

Hysterosalpingography (HSG) METHOD: X-ray the uterus and fallopian tubes with a radio-opaque dye injected as a contrast

• Bloods (Pregnancy test, FBC, Ovulation screen, FSH- Day 2-4, LH- Day 8, Mid-luteal progesterone- Day 21, TFTs, Prolactin)
• Hysteroscopy: NOT a routine procedure but can be used
  • Findings: distorted cavity by fibrous tissue, fallopian ostia may be occluded
• Pelvic USS (Usually normal, Uterus may be partially enclosed by corporal adhesions NOT a reliable diagnostic tool)

Question 5

Management

Answer 5

Cervical probing/ dilation

• If cervical stenosis or cervical pathology leading to Asherman’s syndrome
• USS-guided procedure

Hysteroscopic adhesiolysis

• Manually break down the intrauterine adhesions using blunt or sharp mechanical, electrosurgical instruments
• May use a versapoint bipolar electrode or laser methods
• Hysteroscopic adhesiolysis + post-op copper IUD + PO oestrogens (2-3m) + reassess cavity (PO oestrogens induce endometrial proliferation)

Uterine reconstruction

• Myometrial scoring (surgical intervention) depending on how narrow or partially obliterated the cavity is à
• Use a resectoscope with a Collin’s knife electrode
• 6-8 x 4mm deep long incisions are made into the myometrium, going from the uterine fundus to the isthmus
• This results in increasing the intrauterine dimensions

Question 6

Complications

Answer 6

Subfertility / Infertility

Menstrual disrurbance

Pelvic infection

Complications of HSG- bleeding, cramps, infection

Pregnancy related complications

• Significant risk of placenta accreta
• Miscarriage

 

Question 7

Prognosis

Answer 7

Recurrence of adhesions

Mild Asherman’s – does not really recur

Moderate Asherman’s – 16.75% recurrence

Severe Asherman’s – 41.9% recurrence