Asherman Syndrome: Causes, Symptoms, Diagnosis, Treatment and Related Disorders

Asherman syndrome is a rare and acquired gynecological condition.

It is determined by the formation of adhesions or scar tissue inside the cervix, which produce changes in the menstrual cycle.

In some cases the walls of the uterus adhere to each other and at other times these adhesions only occur in small areas of the uterus.

The type of injury defines its mild, moderate or severe character. These adhesions can be thin or thick and are usually not vascular.

Causes

Endometrial scars and intrauterine adhesions can occur as a result of surgical scraping or cleaning of the uterine wall tissue.

In cases of dilatation and curettage, known as D & C, infections of the endometrium, tuberculosis, use of the device for birth control and surgeries to remove fibroids or polyps , to repair structural defects and cesarean sections.

This syndrome of Asherman occurs when the lesion in the endometrial lining performs the normal process of wound healing, which causes the damaged areas to fuse.

Symptoms of Asherman syndrome

Most patients experience a reduced menstrual flow and eventual cessation of menstrual cycles (amenorrhea), considerable cramping and abdominal pain and in many cases recurrent miscarriages and / or infertility.

Frequently these symptoms occur as a result of severe inflammation of the lining of the uterus, called endometriosis.

This is caused by the development of intrauterine adhesions and synechiae within the uterine cavity, which join parts of the walls of the uterus together, reducing the volume of the uterus.

Diagnosis

Asherman Syndrome has drawbacks for its diagnosis, usually not detected by routine procedures commonly used in gynecology, such as an ultrasound.

It is estimated that the condition affects 1.5% of women undergoing a hysterosalpingogram (HSG), between 5 and 39% of women who have recurrent spontaneous abortion.

Up to 40% of patients undergoing dilation and curettage of the products of conception retained after the birth or in case of incomplete abortion.

The most reliable methods for diagnosis are firstly the hysteroscopy, which is the standard test, since it allows to observe the uterus inside thanks to an endoscope.

Other secondary methods such as ultrasound, sonohysterography (SHG) and hysterosalpingography (HSG) obtain images where adhesions can be observed, such as hypoechoic bands (darker images) crossing the endometrial cavity or as multiple irregular linear filling defects.

Treatment

The main objective of the therapy is to eliminate the adhesions to subsequently restore the size and normal shape of the uterine cavity.

The most common treatment is the lysis of adhesions by surgical hysteroscopy, with the use of resectoscopes or lasers.

The surgery is usually followed by a treatment with antibiotics (before the possibility of producing an infection).

However, the tendency of adhesions to reproduce, especially in severe cases, it is necessary to use an estrogen cycle followed by progesterone.

This hormone therapy is also used to stimulate menstruation.

The reproductive result is correlated with the type of adhesions and the degree of occlusion of the uterine cavity, so the restoration of fertility is another objective of the treatment.

Prevention

Prevention is the best solution, there is evidence to show that women who were treated for failed miscarriage with misoprostol did not develop the syndrome, however 7.7% of those who underwent D & C developed it.

The advantage of the use of misoprostol is that it can be used for the evacuation of the remains not only after the occurrence of a spontaneous abortion, but also for cases of hemorrhage and retained placenta, after delivery.

The alternative use of the D & C technique could be executed, with ultrasound monitoring.

This guarantees that the scraping is less invasive, thus avoiding injuries. Monitor pregnancy in time to identify a miscarriage and prevent the development or recurrence of Asherman syndrome.

Related disorders

There are disorders whose symptoms may be similar to those of Asherman syndrome and certain comparisons may be advantageous to obtain a differential diagnosis:

  • Primary amenorrhea.
  • Secondary amenorrhea.
  • The endometriosis.
  • Pelvic inflammatory disease (PID).

Consequences of Asherman syndrome

Asherman syndrome has reproductive consequences that include recurrent spontaneous abortions, intrauterine growth restriction, infertility, placenta accreta, among others.