Asherman's syndrome.

• Jurisdiction: Australia
• Author: Vancaillie, Thierry G.
• Date: 01 March 2013

Joseph Asherman first described intrauterine adhesions in 1948. It is commonly referred to as Asherman's syndrome (AS), intrauterine synechiae and Fritsch syndrome.

AS is an acquired uterine disorder characterised by the formation of adhesions (scar tissue) within the uterine cavity and/or cervical canal. The majority of AS cases involve the isthmus, which is the transition between the cervix and the cavity.

Prevalence

The true prevalence of AS is unclear due to under-diagnosis. It is estimated to affect 1.5% of women undergoing a hysterosalpingogram (or HSG; a radiologic procedure to investigate the uterine cavity and fallopian tubes); between 5% and 39% of women with recurrent miscarriage; and up to 40% of patients who have undergone repeat dilation and curettage (D&C) for retained products of conception following pregnancy.

Symptoms

The majority of AS patients have no symptoms at all. A decrease in menstrual flow may occur due to menses trapped in the uterine cavity (hematometra) however this is difficult to measure. Patients present for treatment if they fail to become pregnant or if they have significant increase in dysmenorrhea or complete absence of menses.

Most symptoms occur within close proximity to a pregnancy, usually within four months and usually while the woman is in a hypo-oestrogenised state, as after miscarriage or childbirth.

Causes

It must be stressed that each case of AS is different, and the cause must be determined on a case by case basis. There is a pervasive belief that AS develops as the result of aggressive curettage however, in the opinion of Professor Vancaillie a leading AS physician, this is not the case, at least not as a single cause.

Most likely, AS is the result of a set of circumstances including pregnancy (recent), instrumentation and inflammation (possibly due to sub-clinical infection) and a genetic predisposition.

Most commonly AS or intrauterine adhesions occur after a D&C that was performed because of a missed or incomplete miscarriage, retained placenta, postpartum haemorrhage, or abortion. Pregnancy related D&Cs have been shown to account for 90% of AS cases. Sometimes adhesions also occur following other pelvic surgery such as caesarean section, hysteroscopic resection of submucosal fibroids or polyps, or in the developing world, as a result of infections such as genital tuberculosis and schistosomiasis.

However, there appears to be a strong link between repeat curettage (for miscarriage or postpartum haemorrhage) and the occurrence of subsequent intrauterine scarring. This may be because there is a greater likelihood that all the elements necessary to result in AS are more likely to be present if the first curettage was incomplete and the uterus containing the remaining retained products does not heal well and becomes more susceptible to develop intrauterine adhesions.

There is a 25% risk of developing AS from a D&C that is performed close to the time of birth or loss of pregnancy (two...