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Asherman Syndrome

Asherman syndrome refers to a condition in which adhesions (synechiae) are present in the uterus resulting in various complaints, such as amenorrhea and infertility. The condition usually appears after an intrauterine trauma.


Presentation

The prevalence of Asherman syndrome in the general population is not easy to ascertain but it can go so far as 21% in the group of women that had curettage after delivery [1]. Whereas any intrauterine damage can cause adhesions and consequent uterine problems, the majority of adhesions are associated with problems of pregnancy [2], specifically with procedures of curettage performed after deliveries and abortions [1]. The tendency for adhesions to form after repeated miscarriages or use of instrumentation in general on the postpartum uterus is also high [3] [4].

The adhesions in severe cases almost fill up the uterine cavity. The most frequent clinical manifestations are menstrual problems (hypomenorrhea and amenorrhea) and infertility or subfertility [5] [6]. Some reports note a correlation between the extent of uterine damage and the severity of menstrual complaints [1] [7]. A deficient function of the endometrium, which may be due to inadequate perfusion, hinders successful implantation and leads to infertility or repeated miscarriages [8]. Subfertility may also be caused by the adhesions blocking the free advance of the sperm [1]. Cyclical pain may result from blocked menstrual outflow, which may lead to retrograde menstruation.

Falling
  • Myth: Once my scars are removed I can fall pregnant straightaway.[whria.com.au]
  • Fritsch H: Ein Fall von Volligem Schwund der Gebarmutterhohle nach Auskratzung. Zentralbl Gynaekol 18:1337, 1894 2. Asherman JG: Amenorrhea traumatic (atretica). J Obstet Gynaecol Br Emp 55:23, 1948 3. Asherman JG: Traumatic intra-uterine adhesions.[glowm.com]
  • For further information: www.ashermans.org The International Asherman's Association 1 Fritsch H: Ein Fall von Volligem Schwund der Gebarmutterhohle nach Auskratzung. Zentralbl Gynaekol 18:1337, 1894 2 Asherman JG: Amenorrhea traumatic (atretica).[glowm.com]
Rigor
  • Causes of Asherman's Syndrome Scar tissue resulting from a rigorous D&C after a miscarriage. Scar tissue resulting from infection from a therapeutic abortion or PID.[familybuilding.resolve.org]
Prolonged Bleeding
  • ., symptoms of adenomyosis include pelvic pain and abnormal uterine bleeding-either prolonged bleeding from the uterus or irregular bleeding.[sharedjourney.com]
Abdominal Pain
  • Patients may present with infertility, pregnancy loss, menstrual abnormalities (e.g. amenorrhea, hypomenorrhoea, dysmenorrhea) or abdominal pain 1 .[radiopaedia.org]
  • Patients may present with infertility, pregnancy loss, menstrual abnormalities (e.g. amenorrhea, hypomenorrhoea, dysmenorrhea) or abdominal pain 1.[radiopaedia.org]
  • Patients experience reduced menstrual flow, increased cramping and abdominal pain, eventual cessation of menstrual cycles (amenorrhea), and, in many instances, infertility.[rarediseases.org]
  • In Asherman's syndrome, flat scar tissue replaces the functional endometrium which does not respond to hormones and causes changes in the menstrual cycle involving decrease in menstrual flow, cramping and abdominal pain increases, ultimately cessation[planetayurveda.com]
Forgetful
  • Looking very fetching just before my hysteroscopy procedure I will never forget the moment I came round from the operation to be greeted by my wonderful consultant saying to me “you’ll be having babies in no time”. My instincts had been right.[baby.co.uk]
Amenorrhea
  • PATIENT(S): Twelve women with severe Asherman syndrome and amenorrhea.[ncbi.nlm.nih.gov]
  • Asherman syndrome refers to a condition in which adhesions (synechiae) are present in the uterus resulting in various complaints, such as amenorrhea and infertility. The condition usually appears after an intrauterine trauma.[symptoma.com]
  • A 27-year-old Zulu woman, para 1, presented with secondary amenorrhea after an uncomplicated cesarean delivery. Hormone levels were in the normal ranges.[ncbi.nlm.nih.gov]
  • PATIENT(S): Patients with Asherman syndrome who presented with amenorrhea or hypomenorrhea, infertility, or recurrent pregnancy loss.[ncbi.nlm.nih.gov]
  • Prognosis In most cases the prognosis is very good, at least in terms of the scarring and the symptoms it causes (pain and amenorrhea).[pregnancycorner.com]
Secondary Amenorrhea
  • A 27-year-old Zulu woman, para 1, presented with secondary amenorrhea after an uncomplicated cesarean delivery. Hormone levels were in the normal ranges.[ncbi.nlm.nih.gov]
  • Asherman's syndrome secondary amenorrhea in a hormonally normal woman, caused by obliteration of the endometrial cavity by adhesions that form as a result of curettage, infection, or uterine ablation.[medical-dictionary.thefreedictionary.com]
  • Symptoms - Asherman's syndrome Causes - Asherman's syndrome Prevention - Asherman's syndrome Diagnosis - Asherman's syndrome The history of a pregnancy event followed by a D&C leading to secondary amenorrhea is typical.[checkorphan.org]
  • Explore these free sample topics: -- The first section of this topic is shown below -- Basics Description Asherman syndrome (AS) is the term used to describe infertility or secondary amenorrhea associated with intrauterine adhesions (IUAs) or development[unboundmedicine.com]
  • Diagnosis The historical event of pregnancy followed by curettage which leads to secondary amenorrhea or hipomenorrea is typical. Hysteroscopy is the gold standard for diagnosis.[laparoscopyhospital.com]
Oligomenorrhea
  • Often, patients experience side menstrual irregularities characterized by a decrease in the rate and duration of bleeding (amenorrhea, oligomenorrhea or hipomenorrea) and become sterile.[laparoscopyhospital.com]
  • Patients and Methods This was a hospital based descriptive study of one and half year, where patients coming to outpatient department for complaints of secondary ammenorrhoea, oligomenorrhea, or infertility were selected following all routine investigations[jpma.org.pk]
Primary Amenorrhea
  • Primary amenorrhea is when a teenage girl has reached or passed the age of 16 and still hasn’t had her first period. Most girls begin menstruating between ages 9 and 18, but 12 is the average age.[healthline.com]
Uterine Cramps
  • Pelvic pain, if scar tissue blocks the outflow of the menstrual blood, causing uterine cramping and pelvic discomfort or pain.[planetayurveda.com]

Workup

A history revealing problems with infertility and menstruation will raise suspicion of Asherman syndrome. Various imaging methods are used for diagnosing the disease.

Transvaginal ultrasound, while inexpensive and available in most settings, has low sensitivity and specificity in diagnosing Asherman syndrome [9]. However, sonohysterography performed on a uterus filled with saline solution has better sensitivity and predictive capability. Three-dimensional ultrasonography is able to confirm decreased volume of the uterine cavity [10].

Hysterosalpingography, a radiologic procedure which is considered a "historical" method [1] [11], could be helpful in the diagnosis, and the radio-opaque medium used allows the patency of the tubes to be examined [12]. The presence of adhesions is indicated by sharp contours in the image, and if the inside of the uterus is completely occluded, the contrast material is unable to penetrate the uterus.

Hysteroscopy, which can be carried out in an office visit setting, is the gold standard for the diagnosis. It is the most precise method for visualization of the inside of the uterus and can show the location and shape of adhesions [11]. Office hysteroscopy for the diagnosis and treatment of relatively mild adhesions has been shown to increase the pregnancy rate in previously unresponsive women [13].

Classification and grading of cases of Asherman syndrome are problematic because there are several systems in use with different scoring criteria. When the gynecological history of the patient is taken into account in addition to the results of imaging tests, the predictive value of the classification is improved [14] [15]. Nevertheless, there is no universal agreement on which system to use [1].

Hyponatremia
  • The incidence of preterm delivery (2%), placenta previa (1%), stillbirth (1%), postpartum hemorrhage or retained placenta (4%) is generally low. 39 Acute complications of operative hysteroscopy include uterine perforation, fluid overload, and hyponatremia[glowm.com]
  • The incidence of preterm delivery (2%), placenta previa (1%), stillbirth (1%), postpartum hemorrhage or retained placenta (4%) is generally low. 42 Acute complications of operative hysteroscopy include uterine perforation, fluid overload, and hyponatremia[glowm.com]

Treatment

  • Close antenatal surveillance and monitoring are necessary for women who conceive after treatment.[ncbi.nlm.nih.gov]
  • A 29-year-old patient with severe Asherman syndrome, who underwent six operative hysteroscopies combined with hormonal treatment, and no functional receptive endometrium was achieved.[ncbi.nlm.nih.gov]
  • Outcome of treatment Hysteroscopic treatment of Asherman's syndrome can dramatically improve both menstrual problem and reproductive outcome.[ivf-infertility.com]
  • Stem cell therapy method recently has become a novel procedure for treatment of tissue injury and fibrosis in response to damage.[ncbi.nlm.nih.gov]
  • Abstract Asherman syndrome is a debatable topic in gynaecological field and there is no clear consensus about management and treatment.[ncbi.nlm.nih.gov]

Prognosis

  • CONCLUSION(S): The management of moderate to severe disease still poses a challenge, and the prognosis of severe disease remains poor. Close antenatal surveillance and monitoring are necessary for women who conceive after treatment.[ncbi.nlm.nih.gov]
  • CONCLUSION(S): Comprehensive management provides the best possible outcomes in poor-prognosis women with severe Asherman syndrome. Copyright 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • The diagnostic hysteroscopy will allow us to clearly see the adhesions, the degree to which the cavity is affected, the quality of the endometrium, the tubal ostia and the possibilities of real treatment and a prognosis adapted to the severity of the[institutobernabeu.com]

Etiology

  • MAIN OUTCOME MEASURE(S): The etiology, pathology, symptomatology, diagnosis, treatment, and reproductive outcomes were analyzed.[ncbi.nlm.nih.gov]
  • Prevalence Prevalence has been cited as 0.3% incidental finding in women undergoing intrauterine device placement without gynecologic symptoms ( 1 ) 21.5% in women who have undergone postpartum curettage ( 1 ) Etiology and Pathophysiology The etiology[unboundmedicine.com]
  • Spontaneous abortion and recurrent pregnancy loss: etiology, diagnosis, treatment. In: Lobo RA, Gershenson DM, Lentz GM, Valea FA, eds. Comprehensive Gynecology . 7th ed. Philadelphia, PA: Elsevier; 2017:chap 16. Simpson JL, Jauniaux ERM.[mountsinai.org]
  • Spontaneous abortion and recurrent pregnancy loss: etiology, diagnosis, treatment. In: Lobo RA, Gershenson DM, Lentz GM, Valea FA, eds. Comprehensive Gynecology. 7th ed. Philadelphia, PA: Elsevier; 2017:chap 16. Simpson JL, Jauniaux ERM.[nlm.nih.gov]

Epidemiology

  • Epidemiology Incidence As intrauterine adhesive disease is rare and generally asymptomatic, true incidence and prevalence is difficult to measure.[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • Prevalence Prevalence has been cited as 0.3% incidental finding in women undergoing intrauterine device placement without gynecologic symptoms ( 1 ) 21.5% in women who have undergone postpartum curettage ( 1 ) Etiology and Pathophysiology The etiology[unboundmedicine.com]

Prevention

  • Natural Prevention and Healing of Asherman’s Syndrome Systemic Enzyme Therapy for Scar Tissue Prevention Systemic Enzyme Therapy using systemic enzymes helps the body to break-down and prevent scar tissue formation.[natural-fertility-info.com]
  • Research Articles - Gynecologic surgery and adhesion prevention.[adhesions.org]
  • Prevention Ideally, prevention is the best solution.[drmalpani.com]

References

Article

  1. Deans R, Abbott J. Review of intrauterine adhesions. J Minim Invasive Gynecol. 2010;17(5):555-569.
  2. Schenker JG. Etiology of and therapeutic approach to synechia uteri. Eur J Obstet Gynecol Reprod Biol.1996;65:109-113.
  3. Kodaman PH, Arici A. Intra-uterine adhesions and fertility outcome: how to optimize success? Curr Opin Obstet Gynecol. 2007;19:207–214.
  4. Westendorp ICD, Ankum WM, Mol B, Vonk J. Prevalence of Asher- man’s syndrome after secondary removal of placental remnants or a repeat curettage for incomplete abortion. Hum Reprod. 1998;13:3347–3350.
  5. Schenker JG, Margalioth EJ. Intrauterine adhesions: an updated ap praisal. Fertil Steril. 1982;37:593–610.
  6. Klein SM, Garcia C-R. Asherman’s syndrome: a critique and current review. Fertil Steril 1973;24:722–735.
  7. Toaff R, Ballas S. Traumatic hypomenorrhea-amenorrhea (Asherman's syndrome). Fertil Steril. 1978;30(4):379-387.
  8. Polishuk WZ, Siew FP, Gordon R, Lebenshart P. Vascular changes in traumatic amenorrhea and hypomenorrhea. Int J Fertil. 1977;22:189–192.
  9. Salle B, Gaucherand P, de Saint Hilaire P, Rudigoz RC. Transvaginal sonohysterographic evaluation of intrauterine adhesions. J Clin Ultrasound.1999;27(3):131-134.
  10. Weinraub Z, Maymon R, Shulman A, et al. Three-dimensional saline contrast hysterosonography and surface rendering of uterine cavity pathology. Ultrasound Obstet Gynecol. 1996;8(4):277-282
  11. Magos A. Hysteroscopic treatment of Asherman's syndrome. Reprod Biomed Online.2002;4 Suppl 3:46-51.
  12. Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome--one century later. Fertil Steril. 2008;89(4):759-779.
  13. Demirol A, Gurgan T. Effect of treatment of intrauterine pathologies with office hysteroscopy in patients with recurrent IVF failure. RBM Online 2004;8:590–594.
  14. Nasr AL, Al-Inany HG, Thabet SM, Aboulghar M. A clinicohysteroscopic scoring system of intrauterine adhesions. Gynecol Obstet Invest 2000;50:178 –181.
  15. Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical correction. Clin Obstet Gynecol. 2006;49(4):767-788.

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Last updated: 2019-07-11 21:35