Asherman's syndrome

Asherman's syndrome is a disorder characterized by the formation of adhesions (scar tissue) inside the uterus and/or cervix, causing the uterine cavity to narrow. In many cases, the front and back walls of the uterus stick to each other. In other cases, adhesions form in only a small part of the uterus. The number of adhesions determines the severity: mild, moderate, or severe. Adhesions can be thin or thick. They are usually avascular, which is an important attribute that helps in treatment.

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Causes Asherman syndrome

Most often, the causes of this syndrome are - scraping of the uterine mucosa (in case of abortion or miscarriage), various infections, as well as the occurrence of delayed separation of the placenta, etc. These injuries contribute to the formation of intrauterine adhesions. Sometimes adhesions can form as a result of the following pelvic surgeries, such as cesarean section, operations to remove fibroids or polyps, or as a result of infections, such as tuberculosis of the genitals and schistosomiasis.

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Risk factors

At risk are patients who have had a frozen pregnancy. As a result of a miscarriage or curettage, placental remnants appear in the uterine cavity, leading to the activation of fibroblasts, as well as the formation of collagen tissues until the endometrium is restored.

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Symptoms Asherman syndrome

Symptoms of pathologies that develop as a result of adhesive processes manifest as a negative impact on reproductive function. Among the disorders, the following are distinguished:

• menstrual cycle disorders or dysmenorrhea, which manifest themselves in the form of painful and prolonged scanty or heavy periods;
• more complex types of amenorrhea – scanty and rare periods, in which the abundance and duration of menstruation decreases;
• development of hematosalpinx or hematometra, in which menstrual blood begins to accumulate in the uterine cavity and tubes. The reason for this is the same adhesions that block the cervical canal. In this case, there is a pronounced pain syndrome that appears during menstruation due to the fact that blood penetrates through the uterine tubes into the abdominal cavity;
• repeated miscarriages, secondary infertility, and habitual miscarriage.

Most often, Asherman's syndrome develops endometriosis, as well as adenomyosis. As a result, treatment becomes more complicated and the prognosis for recovery worsens. The negative impact on the reproductive system increases.

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Stages

Asherman's syndrome can be classified based on the degree of damage to the uterine cavity, as well as the extent of these lesions:

• at stage 1, adhesions cover less than a quarter of the entire volume of the uterine cavity. They are easily destroyed upon contact with the fallopian tubes (their free orifices). At the same time, adhesions do not affect the tubular orifices and the uterine fundus;
• at stage 2, the adhesions grow in size from a quarter to ¾ of the uterine cavity. In this case, the uterine walls are not affected by synechiae, the lesion affects the tubular openings and the uterine fundus, which can be closed not only partially, but also completely. Such a single adhesion is quite dense and connects isolated areas of the uterine cavity. It cannot be destroyed by contact with the tip of the hysteroscope. Synechiae can also be located in the area of the internal os of the uterus. In this case, the upper parts of the uterine cavity remain unchanged;
• At stage 3, adhesions grow to more than ¾ of the volume of the uterine cavity. In this case, adhesions are very dense and numerous, they connect individual areas inside the uterus. Unilateral obstruction of the fallopian tube opening also develops.

Hysteroscopic classification

• I - thin or film adhesions are easily torn only by a hysteroscope, the horny areas are normal;
• II - singular forms of adhesions connecting individual parts of the uterine cavity, visualization of the fallopian tubes is possible, cannot be torn by a hysteroscope;
  • IIa - occlusion by adhesions of only the area of the internal os of the cervix. The upper cavity of the uterus is normal;
• III - Several forms of adhesions connecting individual parts of the uterine cavity, unilateral obliteration of the fallopian tube;
  • IIIa - Extensive scarring of the uterine cavity wall with amenorrhea or hypomenorrhea;
  • IIIb - Combination of III and IIIa;
• IV - Extensive forms of adhesions with agglutination of the uterine walls. Both openings of the tubal sections are occluded.

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Classification according to Donnez and Nisolle

I - central adhesions

• a) thin adhesions of the film (intrauterine adhesions)
• b) myofibrosis (connective tissue adhesions)

II - Marginal adhesions (always myofibrous or connective tissue)

• a) Wedge-shaped deformation of the uterus
• b) Adhesion of one horn

III - The uterine cavity is absent during hysteroscopy

• a) obstruction of the internal os (upper cavity is normal)
• b) extensive agglutination of the uterine walls (absence of the uterine cavity - true Asherman's syndrome)

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Forms

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

• lungs that resemble a film (they can be easily cut with the tip of a hysteroscope);
• medium ones, which are of fibromuscular nature (they bleed after cutting);
• heavy ones that tightly connect tissues (they are quite difficult to cut).

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Complications and consequences

Complications of Asherman syndrome include the following disorders:

• development of uterine infertility, repeated miscarriages, intrauterine growth retardation;
• hematometra - as a result of a disruption in the outflow of physiological bleeding from the uterus (due to adhesions localized in the lower part of the uterine cavity), menstrual blood accumulates inside it;
• pyometra - as a result of the development of infection, pus accumulates in the uterine cavity.
• Women with Asherman syndrome may develop uterine cancer before or after menopause.

Complications involving the fallopian tubes:

• development of tubal-peritoneal type of infertility;
• ectopic pregnancy (in which the fertilized egg is implanted in the fallopian tube), which can result in severe bleeding that can be fatal;
• regular pain in the lower abdomen - chronic pelvic pain.

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Diagnostics Asherman syndrome

Diagnosis of the disease is carried out based on the following methods:

• the patient's history of complaints is analyzed, as well as the history of pathology (it is determined whether the woman had menstruation, at what point it stopped, whether the patient feels pain, and if so, what is its nature. It is also determined whether there are problems when trying to conceive, etc.);
• the patient's medical history is analyzed for gynecological diseases, sexually transmitted diseases, surgeries, the number of abortions and pregnancies (if any), etc.;
• the menstrual function of the body is analyzed (age at the onset of the first menstruation, regularity and duration of the cycle, and in addition, the date of the last menstruation, etc.);
• a gynecological examination, during which a bimanual examination of the vagina is performed. The doctor palpates the genitals with both hands to determine whether they are properly developed, as well as the size of the ovaries, uterus, cervix, and the relationship between them. At the same time, the condition of the appendages (pain, mobility) and the ligamentous uterine apparatus are assessed.

Instrumental diagnostics

Among the methods of instrumental diagnostics:

• hysterosalpingography is an X-ray of the uterine cavity and tubes, which determines the presence of adhesions, their location and quantity, as well as the patency of these organs;
• Ultrasound of the uterus and tubes using sonohysterography (the uterus is filled with water) to determine the presence of adhesions, as well as curvature of the uterine cavity;
• laparoscopy - an endoscope (a long tube with a camera at the tip) is inserted into the abdominal cavity, which can be used to obtain a picture of the organs located in the peritoneum and determine the presence of adhesions. Sometimes this procedure can be used not only for diagnostics, but also for treatment - when adhesions are cut during laparoscopy.

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Treatment Asherman syndrome

The pathology is treated surgically - this is the most effective method. But before the operation, a number of preparatory procedures must be performed to create reversible atrophy of endometrioid tissues - this simplifies the operation. For this, hormonal drugs are prescribed that suppress the process of formation and growth of the endometrium.

It is necessary to carry out therapy after the operation (and a maximum of 1.5 days after its completion). The procedure should be repeated after the first menstruation after the operation. The number of such treatment courses is determined individually, but usually a maximum of 3 courses is required, with a minimum interval of 3 months between them. After surgery, you need to be monitored by a doctor for 6 months.

Medicines

In the postoperative period, it is necessary to conduct hormonal therapy (duration - 3 months) - continuously take progesterone with estrogen. These drugs are mainly prescribed to ensure better wound healing. A course of antibiotics is also carried out to prevent the development of infection.

Physiotherapy treatment

As additional treatment methods, physiotherapeutic procedures are carried out, which help to accelerate the healing process, strengthen the body's immunity and prevent the formation of new intrauterine adhesions.

For this purpose, laser procedures are prescribed and currents with a supra-tonal frequency are used, as well as the properties of magnetic fields (constant or variable).

Surgical treatment

Treatment of Asherman's syndrome using surgical methods: rupture or dissection of intrauterine adhesions is performed. A special device, a hysteroscope, is used for this. It is inserted into the uterus through the vagina and cervix. The procedure is called hysteroscopy.

Prevention

To prevent the disease, you should follow these rules: refuse abortions, perform intrauterine procedures or operations reasonably and carefully. You should also promptly treat any genital infections that appear and regularly undergo examinations by a gynecologist.

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Forecast

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

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