Asherman's Syndrome

Asherman's syndrome is a disease characterized by the formation in the inside of the uterus and / or cervix of the uterus of adhesions (scar tissue), resulting in a narrow uterine cavity. In many cases, the front and back walls of the uterus stick to each other. In other cases, spikes are formed only in a small part of the uterus. The number of adhesions determines the degree of severity: mild, moderate or severe. Spikes can be thin or thick. They are usually not vascular, which is an important attribute that helps in the treatment.

[1], [2]

Causes of the asherman syndrome

The most common causes of this syndrome are scraping of the uterine mucosa (in the case of abortion or miscarriage), various infections, as well as the appearance of delayed separation of the aftereffect, etc. These lesions contribute to the formation of intrauterine adhesions. Sometimes spikes can result from the following pelvic surgeries, such as caesarean section, surgery for the removal of fibroids or polyps, or as a result of infections such as genital tuberculosis and schistosomiasis.

[3], [4]

Risk factors

At risk are patients who have suffered a dead pregnancy. As a result of miscarriage or curettage in the uterine cavity, the placenta remains, leading to the activation of fibroblasts, as well as the formation of collagen tissue before the restoration of the endometrium.

[5],

Symptoms of the asherman syndrome

Symptoms of pathologies that develop as a result of adhesions are manifested as a negative effect on reproductive function. Among the violations are as follows:

• disorders of the menstrual cycle or dysmenorrhea, which manifest themselves in the form of painful and prolonged meager or profuse menstrual periods;
• more complex variants of amenorrhea - scanty and rare monthly, in which the abundance and duration of menstruation decreases;
• the development of hematosalping or hematoma, in which menstrual blood begins to accumulate in the uterine cavity and tubes. The reason for this is the very splices, due to which the cervical canal is blocked. In this case, there is a pronounced pain syndrome that appears during menstruation due to the fact that blood penetrates through the tubes of the uterus into the abdominal cavity;
• repeated miscarriages, secondary infertility, as well as habitual miscarriage.

Most often, asherman syndrome develops endometriosis, as well as adenomyosis. As a result, the treatment becomes more complicated and the prognosis for recovery is worsening. The negative impact on the reproductive system is increasing.

[6], [7]

Stages

Asherman's syndrome can be classified, starting from the degree of defeat of the uterine cavity, as well as the extent of these lesions:

• at the first stage, spikes cover less than a quarter of the total volume of the uterine cavity. They can easily be destroyed by contact with the fallopian tubes (their free mouths). In this case, the spikes do not affect the tubular mouth and the uterine bottom;
• at the second stage the adhesions grow in sizes from a quarter to ¾ of the uterine cavity. In this case, the uterine walls are not affected by the synechiae, the lesion affects the tubular mouth and the uterine bottom, which can be closed not only partially but also completely. This single spike is quite dense and connects isolated areas of the uterine cavity. It can not be destroyed by contact with the tip of the hysteroscope. Synechia can also be located in the area of the internal pharynx of the uterus. In this case, the upper sections of the uterine cavity remain unchanged;
• at the third stage, the adhesions grow to more than ¾ of the uterine cavity volume. In this case, the adhesions are very dense and numerous, they connect individual areas within the uterus. One-sided obstruction of the mouth of the fallopian tube also develops.

Hysteroscopic classification

• I - thin or film adhesions are easily broken only by the hysteroscope, horny areas are normal;
• II - singular forms of adhesions that connect individual parts of the uterine cavity, visualization as fallopian tubes is possible, can not be broken by a hysteroscope;
  • IIa - occlusion with spikes only the area of the internal throat of the cervix. The upper uterine cavity is normal;
• III - Several forms of adhesions connecting individual parts of the uterine cavity, unilateral obliteration of the uterine tube;
  • IIIa - Extensive scarring of the wall of the uterine cavity with amenorrhea or hypomenorrhea;
  • IIIb - The combination of III and IIIa;
• IV - Extensive forms of adhesions with agglutination of uterine walls. Both mouths of the pipe sections are occluded.

[8], [9], [10]

Classification by Donnez and Nisolle 

I - central joints

• a) thin film adhesions (intrauterine adhesions)
• b) myofibrous (connective tissue adhesions)

II - Marginal adhesions (always myofibrous or connective tissue)

• a) Cuneiform deformation of the uterus
• b) Clumping of one horn

III - There is no uterine cavity during hysteroscopy

• a) blockage of internal pharynx (upper cavity normal)
• b) extensive agglutination of the uterine walls (absence of uterine cavity - true Asherman syndrome)

[11], [12]

Forms

Intrauterine spikes are divided into 3 types according to their histological properties:

• Light, which are similar to film (they can easily be cut by the tip of the hysteroscope);
• medium, which are of a fibrous-muscular nature (they bleed after dissection);
• Heavy, which tightly connect the tissues (they are quite difficult to cut).

[13], [14]

Complications and consequences

Complications of the Asherman syndrome are such violations:

• development of uterine infertility, repeated miscarriages, intrauterine growth retardation;
• hematometer - due to the violation of the outflow of physiological bleeding from the uterus (because of the adhesions localized in the lower part of the uterine cavity), menstrual blood accumulates inside it;
• piometer - due to the development of infection in the uterine cavity pus accumulates.
• Women with Asherman syndrome can develop uterine cancer before or after menopause.

Complications that extend to the fallopian tubes:

• development of tubal-peritoneal type of infertility;
• ectopic pregnancy (the fertilized egg is fixed in the fallopian tube), which can lead to severe bleeding, which can lead to death;
• regular pain in the lower abdomen - pelvic pain in chronic form.

[15], [16], [17]

Diagnostics of the asherman syndrome

The diagnosis of the disease is based on the following methods:

• the history of the patient's complaints is analyzed, as well as the history of the pathology (it is found out whether the woman has had menstruation, at what point they stopped, whether the patient feels pain, and if so, what their nature is.) Also find out if there are problems in attempting to conceive, );
• the history of the patient's gynecological diseases, sexually transmitted diseases, operations, the number of abortions and pregnancies (if they were), etc .;
• the menstrual function of the organism is analyzed (the age at the onset of the first menstruation, the regularity and duration of the cycle, and in addition the date when the last menstruation, etc.);
• An examination with a gynecologist, in which a two-handed examination of the vagina is carried out. In this case, the doctor palpates the genitals with both hands to determine whether they are properly developed, and in addition the size of the ovaries, uterus, uterine neck, and also the ratio between them. Together with this, the appendages are evaluated (pain sensations, mobility) and ligamentous uterine apparatus.

Instrumental diagnostics

Among the methods of instrumental diagnostics:

• Hysterosalpingography is the x-ray of the uterine cavity and tubes, which determines the presence of adhesions, their location and quantity, and the patency of these organs;
• Ultrasound of the uterus and tubes using sonogetherography (the uterus is filled with water) to determine the presence of adhesions, as well as the curvature of the uterine cavity;
• laparoscopy - in this case, an endoscope is inserted into the abdomen (a long tube with a camera on the tip), through which it is possible to obtain a picture of the organs located in the peritoneum and to determine the presence of adhesions. Sometimes, with this procedure, you can perform not only diagnosis, but also treatment - when the adhesions dissect during laparoscopy.

[18], [19]

Treatment of the asherman syndrome

Treatment of pathology is carried out surgically - this is the most effective method. But before the operation, a number of preparatory procedures are required to create a reversible atrophy of the endometrioid tissues - this simplifies the operation. For this purpose, hormonal drugs are prescribed, which suppress the process of formation and growth of the endometrium.

It is necessary to carry out therapy after the operation (and maximum after 1.5 days after its completion). Repeat the procedure should be after the first few months after the operation. The number of such treatment courses is determined individually, but usually a maximum of 3 courses is required, the minimum interval between which is 3 months. After surgical intervention, it is necessary for 6 months. To be observed at the doctor.

Medications

In the postoperative period, hormonal therapy (duration - 3 months) should be taken - continuously taking progesterone with estrogen. These drugs are mainly prescribed to provide better wound healing. Also, a course of antibiotic treatment is conducted to prevent the development of infection.

Physiotherapeutic treatment

As additional methods of treatment are carried out physiotherapeutic procedures that contribute to speeding up the healing process, strengthen the body's immune system and prevent the formation of new intrauterine adhesions.

For this, laser procedures are used and the currents having a supersonic frequency are used, as well as the properties of magnetic fields (constants or variables).

Operative treatment

Treatment of Asherman's syndrome with the help of surgical methods: the rupture or dissection of the intrauterine adhesions is performed. For this, a special apparatus is used - the hysteroscope. It is injected into the uterus through the vagina and the uterine neck. The procedure is called hysteroscopy.

Prevention

As a preventive measure of the disease should adhere to such rules - to abort abortion, reasonably and carefully perform intra-uterine procedures or operations. Also, it is necessary to treat the emerging genital infections in a timely manner and regularly undergo examinations with a gynecologist.

[20], [21], [22]

Forecast

Asherman's syndrome with a timely and proper treatment has a favorable prognosis. But it must be taken into account that in some cases a relapse of the disease can occur. Later, after dissection of the intrauterine adhesions, much depends on such factors as the area of distribution and the volume of adhesions, and in addition the degree of obstruction of the uterine cavity.

[23], [24]