Intrauterine Adhesions Ashermans Syndrome

Intrauterine scarring leading to an unresponsive endometrium is most commonly due to injury to the pregnant or recently pregnant uterus. However, any mechanical, infectious, or radiation factor can produce endometrial sclerosis and adhesion formation. The sine qua non for development of IUA is endometrial trauma, especially to the basalis layer. The adhesions usually are strands of avascular fibrous tissue, but they also may consist of inactive endometrium or myometrium. Myometrial adhesions usually are dense and vascular, carrying a poor prognosis. Women with atrophic and sclerotic endometrium without adhesions carry the worst prognosis. This condition usually is found after radiation or tuberculous endometritis and is not amenable to any therapy. Postpartum curettage performed between the second and fourth weeks after delivery, along with hypoestrogenic states such as breast-feeding or hypogo-nadotropic hypogonadism, is associated with extensive intrauterine scar formation. Uterine curettage performed after a missed abortion is associated with a higher incidence of intrauterine synechiae than curettage performed after an incomplete abortion. Adhesions may also form after a diagnostic D&C. In general, the routine use of uterine curettage at the time of a diagnostic laparoscopy is unwarranted and may damage the endometrium.

IUA should be suspected if a woman presents with secondary amenorrhea, a negative pregnancy test, and does not have progestin-induced withdrawal bleeding. There is no consistent correlation between the menstrual bleeding patterns and the extent of IUA. The diagnosis of IUA should be suspected in every patient with infertility, recurrent abortions, uterine trauma, and menstrual abnormalities. The most common method for diagnosing IUA is the hysterosalpingogram. In cases of severe IUA, the cavity cannot be sounded, making the procedure very difficult to perform. Vaginal ultrasound can be used for the diagnosis of IUA; however, it lacks specificity. Sonohysterography is an excellent complement to the vaginal ultrasound and can allow for evaluation of the uterine cavity. Magnetic resonance imaging (MRI) is expensive and does not offer a greater advantage over the other diagnostic modalities. Hysteroscopy allows for direct visualization of the uterine cavity and is considered the "gold standard" for establishing the diagnosis and extent of IUA.

Operative hysteroscopy is the ideal treatment of IUA. Postoperative management may include insertion of a loop intrauterine device or a pediatric Foley catheter to prevent the recently lysed adhesions from reforming. In addition, administration of conjugated estrogens and progesterone (medroxyprogesterone acetate) should be considered. The uterine cavity should be reevaluated prior to attempting conception.

Comprehension Questions

[42.1] A 34-year-old woman states that she has had no menses since she had a uterine curettage and cone biopsy of the cervix 1 yr previously. Since those surgeries, she complains of severe, crampy lower abdominal pain "similar to labor pain" for 5 days of each month. Her basal body temperature chart is biphasic. rising 1°F for 2 weeks of every month. Which of the following is the most likely etiology of secondary amenorrhea?

A. Hypothalamic etiology

B. Pituitary etiology

C. Uterine etiology

D. Cervical condition

[42.2] Which of the following statements about Asherman's syndrome (intrauterine adhesions) is true?

A. Usually occurs after uterine curettage for a pregnancy-related process

B. Best diagnosed by laparoscopy

C. Usually associated with cramping pain every month

D. Treatment includes endometrial ablation

[42.3] A 37-year-old woman is noted to have 6 months of amenorrhea. Previously her menses were monthly. She is not pregnant. Initially progestin therapy does not lead to menstrual bleeding. Sequential administration of estrogen and progestin (estrogen alone for 15 days, then estrogen and progestin together for 10 days) also does not reveal any bleeding. Which of the following is the most likely diagnosis?

A. Hypothalamic dysfunction

B. Intrauterine adhesions

C. Ovarian failure

D. Pituitary dysfunction

[42.4] A 41-year-old woman is suspected of having intrauterine adhesions because she has had irregular menses since a spontaneous abortion 18 months previously. Which of the following historical or laboratory pieces of information support this diagnosis?

A. Presence of hot Hushes

B. Follicle-stimulating hormone level too low to be measurable

C. Normal estradiol levels for a reproductive-age woman

D. Monophasic basal body temperature chart

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