Read more about this disease, some with Classification – Types – Signs and symptoms – Genetics – Pathophysiology – Diagnosis – Screening – Prevention – Treatment and management – Cures and much more, some including pictures and video when available.
Asherman’s syndrome, also called “uterine synechiae” or intrauterine adhesions, presents a condition characterized by the presence of scars within the uterine cavity.
The cavity of the uterus is lined by the endometrium. This lining is composed of two layers, the functional layer which is shed during menstruation and an underlying basal layer which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or for elective abortion can lead to the development of intrauterine scars resulting in adhesions which can obliterate the cavity to varying degrees. In the extreme, the whole cavity has been scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogens and rests. Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding (amenorrhea, hypomenorrhea, or oligomenorrhea)[1] and become infertile. Menstrual anomlies are often but not always correlated with severity: adhesions restricted to only the cervix or lower uterus may block menstruation. Pain during menstruation and ovulation are also sometimes experienced, and can be attributed to blockages.
Asherman’s syndrome occurs most frequently after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or elective termination (abortion) to remove retained products of conception/placental remains. As the same procedure is used in all three situations, Asherman’s can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related curettage.[2] It is estimated that up to 5% of D&Cs result in Asherman’s. More conservative estimates put this rate at 1%. Asherman’s results from 25% of D&Cs performed 1-4 weeks post-partum[3],[4][5] 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages.[6] In the case of missed miscarriages, the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30.9%[2][7] The risk of Asherman’s also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs.[8]
Depending on the degree of severity, Asherman’s syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies[9](see Prognoses below). There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to endometriosis.[5]
Asherman’s can also result from other pelvic surgeries including Cesarean sections,[2][10] removal of fibroid tumours (myomectomy) and from other causes such as IUDs, pelvic irradiation, schistosomiasis[11] and genital tuberculosis.[12] Chronic endometritis from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat.[13]
An artificial form of Asherman’s syndrome can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy.
The condition is estimated to affect 1.5% of women undergoing HSG,[14] between 5 and 39% of women with recurrent miscarriage[15][16][17] and up to 40% of patients who have undergone D&C for retained products of conception.[18] The true prevalence of Asherman’s syndrome is unclear as many doctors are unaware of the symptoms or diagnosis. Increased awareness about the condition and its diagnosis is also expected to reveal a higher frequency than previously reported.
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