Intrauterine adhesions (Asherman syndrome)
Intrauterine adhesions (Asherman syndrome) are fibrous bands within the endometrial cavity, most often from dilation and curettage after a pregnancy-related procedure, causing hypomenorrhea or amenorrhea, infertility, and recurrent pregnancy loss; diagnosis is made by direct visualization on hysteroscopy, and treatment is hysteroscopic adhesiolysis followed by postoperative estrogen therapy to regenerate the endometrium.
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What this article covers
- Overview
Fibrous scar tissue within the endometrial cavity: intrauterine adhesions (Asherman syndrome when symptomatic) are fibrous bands and adhesions that form within the uterine cavity from damage to the…
- Epidemiology
Occurs in women with a history of uterine instrumentation, most often after dilation and curettage performed for a pregnancy-related indication such as postpartum hemorrhage or missed/incomplete miscarriage.
- Risk factors
Dilation and curettage, especially in the pregnant or recently pregnant uterus, which is more vulnerable to basal layer injury than the nonpregnant uterus; postpartum hemorrhage and missed or…
- Pathophysiology
Injury to the basal layer of the endometrium: the basal layer, which normally regenerates the functional endometrium each cycle, is damaged by trauma (curettage) or infection/inflammation (endometritis, pelvic inflammatory disease).
- Clinical features
Absent or markedly decreased menses following uterine instrumentation: the leading and most specific clue; new hypomenorrhea or amenorrhea developing after a dilation and curettage or other…
- Differential diagnosis
Hypothalamic amenorrhea: amenorrhea from low gonadotropin drive (stress, weight loss, excessive exercise) with a positive response to an estrogen-progesterone challenge test, unlike the negative response seen with intrauterine adhesions.
- Diagnosis
Confirmed by direct visualization of adhesions on hysteroscopy, which is both the diagnostic gold standard and the therapeutic procedure; hysteroscopy allows the adhesions to be seen, characterized, and treated in the same setting.
- Management
First, confirm the diagnosis and plan for operative hysteroscopy, since hysteroscopic adhesiolysis under direct visualization is the definitive first-line treatment for symptomatic intrauterine adhesions.
- Complications
Infertility, from loss of functional endometrium and a distorted cavity that impairs implantation.
- Prognosis
Menstrual function and fertility improve after hysteroscopic adhesiolysis and estrogen-stimulated endometrial regeneration in most women, though outcomes depend on the severity and extent of the original adhesions.
- Prevention
Minimize uterine instrumentation when clinically avoidable, particularly repeated dilation and curettage for the same pregnancy-related indication, since each additional procedure adds cumulative risk of basal layer injury.
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