30 Jan Asherman’s Syndrome and How it is Diagnosed and Managed
Asherman’s syndrome is a gynecological condition that is characterized by fibrosis or adhesion formation on the inner lining of the uterus (endometrium) and possibly the muscular wall of the uterus (myometrium).
The causes of Asherman’s syndrome may include:
- Trauma to the basal layer of the uterus, the function of which is to regenerate the functional layer of the organ that breaks down during menstruation. The result is the formation of adhesions that can affect the uterus to varying degrees. Trauma to the basal layer may occur with procedures such as dilatation and curettage performed for surgical termination of a pregnancy or done after a miscarriage to remove products of conception.
- Genital tuberculosis can lead to chronic endometritis which is a significant cause of severe intrauterine adhesions. This condition can cause such severe adhesions that the entire uterine cavity may become occluded.
- Caesarean sections.
- Myomectomy procedures.
- Intra-uterine devices.
- Pelvic irradiation.
- Pseudo-Asherman’s syndrome may occur with endometrial ablation in women with excessive bleeding.
Symptoms and signs of the condition may include:
- A history of having received a recent dilatation and curettage procedure.
- Absent or reduced menstrual bleeding.
- Infrequent menstruation.
- Issues with conception (infertility).
- Pelvic pain experienced during menstruation or ovulation.
A history of having had a dilatation and curettage procedure performed followed by reduced or absent menstruation should make one suspect adhesion formations in the uterus.
A hysterosalpingogram or sonohysterography can be performed to show the extent of uterine adhesions if there are any present.
The gold standard for confirming the diagnosis of Asherman’s syndrome is by performing a hysteroscopy. The steps of the procedure are as follows:
- The patient is administered a general anesthetic so they are asleep during the procedure.
- With the patient lying supine and in the lithotomy position (on her back with the legs in stirrups), a slender scope is inserted into the vagina.
- The cervix is widened/dilated so that the camera (hysteroscope) can be inserted into the uterus.
- A safe liquid or gas, such as carbon dioxide, is passed through the camera into the uterus to expand the organ to get rid of any mucus or blood so that the surgeon can visualize the area better.
- The gynecologist then shines a light through the hysteroscope so that the uterus and the entrances to the fallopian tubes can be inspected.
Ultrasound isn’t a reliable investigation for diagnosing the condition and hormonal studies don’t demonstrate any abnormal laboratory values.
While performing a hysteroscopy, if adhesions are visualized they will be removed using another slender instrument to cut away at the adhesions (adhesiolysis).
Dissecting the adhesions may be technically difficult, so experienced gynecologists will perform the procedure. If the cases are complex, another surgeon will be asked to help by additionally performing a laparoscopy together with the initial doctor performing the hysteroscopy.
In one study, where 27 participants had hysteroscopic adhesiolysis performed on them:
- None had experienced any post-surgical complications.
- All of the women had normal menstrual cycles after the procedure.
- Nine of the 16 infertile patients were able to conceive.
- Four of the patients carried their pregnancies to full term.
- None of the patients had any obstetric complications.
- The conclusion was that this is a safe and effective procedure for managing infertility caused by Asherman’s syndrome.