Asherman's Syndrome

Philip G. Brooks MD
Scott P. Serden MD
Basics
Description
The development of intrauterine adhesions (synechiae) subsequent to some
traumatic intervention, and often but not always associated with amenorrhea
and reduced fertility
Categories divided by severity of the occlusion of the endometrial cavity:

Minimal: <1/4 of cavity involved; ostia and upper fundus relatively

clear

Moderate: 1/43/4 of cavity involved; upper fundus partially occluded

Severe: >3/4 of cavity involved, ostia occluded

Related Conditions: Amenorrhea; Hypomenorrhea; Postabortal amenorrhea;

Postcurettage adhesions

Age-Related Factors
Asherman syndrome is most common in the reproductive years, as it most
often occurs secondary to curettage following abortion or for bleeding
subsequent to delivery.
Prognosis for fertility following treatment is age-related, with younger women
having a better prognosis.
Epidemiology
Virtually only occurs in women during their reproductive years.
Risk Factors
Pregnancy:
o Postpartum bleeding
o

Postabortal bleeding

Sharp curettage

Hypoestrogenic state

Infection/Endometritis

Congenital uterine anomaly (uterine septum)

Intrauterine surgery for septum, submucosus myomas, large polyps

Abdominal metroplasty

Abdominal myomectomy wherein the cavity is entered

Repeated pregnancy loss

Retained portion of placenta, adherent placenta

Cesarean section wherein the back wall accidentally is caught in the anterior
wall suture

Pathophysiology
When opposing walls of the endometrium are denuded or damaged by surgical
or mechanical trauma, or infections, rapid regrowth of the normal
endometrium is inhibited due to the presence of hypoestrogenicity (as with
postpartum or postabortal states).
Agglutination of only endometrial surfaces produces delicate adhesions that
are easy to separate.

Scar formation between myometrial surfaces is more avascular and prevents

endometrial regrowth, resulting in dense, fibrous, and more extensive scar
formation, especially in the presence of infection.

Similarly, intrauterine surgery using scissors or with energy sources

(electrosurgery, laser surgery, etc.) can result in scarring between traumatized
opposing surfaces.

Associated Conditions
Secondary amenorrhea
Previous gynecologic surgery

Dysmenorrhea

Secondary infertility

Pelvic tuberculosis

Diagnosis
Signs and Symptoms
1st symptom usually is amenorrhea or hypomenorrhea following a pregnancy,
either a term pregnancy or a miscarriage or termination, especially where
sharp curettage was performed for subsequent bleeding.
Dysmenorrhea may occur in patients wherein pockets of blood in the uterus
have lost continuity with the endometrial and cervical canals.

Unexplained infertility may occur in patients with a history of uterine surgery,

even with normal menstrual patterns.

Failure to have withdrawal bleeding after hormonal treatment

History

A high degree of suspicion of intrauterine adhesions should be entertained in

patients with menstrual abnormalities or infertility following intrauterine
instrumentation of any type, especially when such instrumentation occurred
after a pregnancy.
Compare menstrual flow characteristics from before the instrumentation to
those following it.
Review of the type of instrumentation that occurred (review operative note),
sharp curettage being the most dangerous in predisposing adhesion formation.

Careful history to rule out systemic endocrine problems that can interfere with
ovulation and menstruation (eating disorders, inappropriate lactation, excess
exercising, hypothyroidism, androgen excess, etc.)

Physical Exam
No physical exam findings are suspicious for or diagnostic of intrauterine
adhesions.
General physical and bimanual exams to rule out pregnancy or ovarian
enlargement.
Tests
Labs

No laboratory findings are suggestive or diagnostic of intrauterine adhesions.

Because of the disruption of normal menstrual pattern, urine or blood hCG
may be useful to rule out pregnancy.

Blood tests to rule out androgen excess, thyroid dysfunction, hypopituitarism,

etc.

Imaging
Transabdominal or transvaginal ultrasound, with or without saline infusion,
can delineate the presence or absence of an endometrial stripe, the area of
obliteration, and the area of blood accumulation, if any.
Hysterography can show the location of the obstruction or the presence and
size of synechiae.

MRI could be used to delineate the contour and defects of the endometrial
cavity, although this is not the preferred imaging modality because of expense.

Hysteroscopy:
o

Office or hospital outpatient diagnostic hysteroscopy may be definitive

to detect and define the extent of synechiae.

Differential Diagnosis
Other causes of acquired amenorrhea and hypomenorrhea:
o Pregnancy

Endocrine dysfunction

Menopause

Other causes of intrauterine defects seen on imaging:

o

Submucous myomas

Endometrial polyps

Retained placental fragments

Intrauterine foreign bodies (IUD fragments, etc.)

Management
General Measures
The primary treatment of uterine synechiae is surgical.
Scattered reports of transabdominal bivalving of the uterus in an attempt to
delineate and reconstruct the endometrial cavity in severe cases have reported
only minimal success.

Operative hysteroscopy with mechanical instrumentation (scissors, flexible or

rigid) is the preferred method of repair, using laparoscopic guidance in severe
cases, to avoid uterine perforation.

The goals are:

o

To restore the endometrial architecture to normal.

To provide continuity of the tubal lumen into the endometrial cavity

for future reproduction.

To prevent recurrent scarring.

To restore normal menstruation, if possible.

In the case of secondary infertility, to all establishment of pregnancy.

P.71
Medication (Drugs)
No medical treatment is capable of reducing or destroying uterine adhesions.
High-dose estrogen therapy, with sequential progesterone for withdrawal, is
advocated as prevention of adhesions, to be instituted immediately after
instrumentation (e.g., sharp curettage) for postpartum or postabortal bleeding,
and after hysteroscopic repair of adhesions, especially when dense or
extensive:
o

Conjugated estrogens 2.5 mg, once or twice daily for 23 cycles.

Medroxyprogesterone 10 mg/d 2028 of each cycle to prevent

endometrial hyperplasia.

Consider prophylactic antibiotics on the day of hysteroscopic surgery.

Surgery
Mechanical interference with adhesion reformation is important to reduce the
risk of regrowth of adhesions after surgical repair:
o Sound the uterine cavity of 12 weeks after hysteroscopic incision.
o

Immediately insert a Foley catheter or silastic balloon into the

endometrial cavity after the surgery; prescribe antibiotics (doxycycline
100 mg b.i.d.); remove balloon after 57 days.

Immediately insert an IUD (Lippes Loop preferred over copper- or

progesterone-containing IUDs due to larger surface area and lack of
chemical influence on healing).

Followup
Disposition
Monitor menstrual function
Menstrual calendar to note timing and quality of flow
Prognosis
Reproductive outcome is related to severity of the adhesions, varying from 94% term
pregnancies after resection of mild adhesion to 79% after repair of severe adhesions.
Patient Monitoring
Starting in the 3rd or 4th cycle after surgery and repeat periodically, depending on the
resumption and quality of menses:
Hysteroscopy, office or outpatient
Saline-infusion sonography

Hysterography

Bibliography
March CM, et al. Hysteroscopic management of intrauterine adhesions. Am J Obstet
Gynecol. 1978;130:653.
Sugimoto O. Diagnostic and therapeutic hysteroscopy for traumatic intrauterine
adhesions. Am J Obstet Gynecol. 1978;131:539.
Valle RF, et al. Intrauterine adhesions: Hysteroscopic diagnosis, classification,
treatment, and reproductive outcome. Am J Obstet Gynecol. 1998;158:1459.
Miscellaneous
Synonym(s)
Intrauterine adhesions
Intrauterine synechiae
Clinical Pearls
Uterine curettage, especially for postpartum or postabortal bleeding, is at high risk
for the development of Asherman syndrome.
If bleeding requires intervention, prevention of adhesions may occur with the use of
blunt or suction curettage only, the prophylactic use of antibiotics, and cyclic estrogen
and progesterone treatment.
Operative hysteroscopy is the best method of treatment for this condition.
Abbreviations
hCGHuman chorionic gonadotropin
Codes
ICD9-CM
621.5 Asherman's syndrome
621.5 Intrauterine adhesions
626.0 Amenorrhea
Patient Teaching
ACOG Patient Education Pamphlet: Asherman's syndrome available at
http://www.acog.org