What disorder can damage to the endometrium cause?

Damage to the Endometrium Can Cause Asherman's Syndrome

Damage to the endometrial-myometrial interface most commonly leads to Asherman's syndrome, characterized by intrauterine adhesions that can cause amenorrhea, infertility, and pregnancy complications. 1

Pathophysiology of Asherman's Syndrome

Asherman's syndrome develops when trauma to the endometrium, particularly to the basal layer, results in the formation of intrauterine adhesions. These adhesions can range from filmy to dense fibrous bands that partially or completely obliterate the uterine cavity 2. The pathophysiology involves:

• Damage to the endometrial-myometrial interface leading to failure of normal endometrial regeneration 3
• Formation of fibrous connective tissue bands with or without glandular tissue 2
• Development of scar tissue that prevents normal endometrial growth 1

Common Causes of Endometrial Damage

The most frequent causes of endometrial damage leading to Asherman's syndrome include:

• Uterine curettage: Particularly vigorous curettage performed during or shortly after pregnancy (within 4 months) 2
• Uterine surgeries: Including myomectomy (both abdominal and hysteroscopic), removal of uterine septae, and other intrauterine procedures 2
• Endometrial infections: Postpartum or post-abortion infections 1
• Prior uterine surgeries or curettage: A significant risk factor for other complications like placenta accreta spectrum 3

Clinical Manifestations

Patients with Asherman's syndrome typically present with:

• Menstrual abnormalities: Ranging from hypomenorrhea to complete amenorrhea 1, 2
• Infertility: Difficulty conceiving due to impaired implantation 4
• Recurrent pregnancy loss: Due to inadequate endometrial development 4
• Cyclic pelvic pain: In some cases, due to "trapped" menstrual blood 5
• Pregnancy complications: Including placenta accreta, previa, and intrauterine growth restriction in those who do conceive 5

Diagnosis

Diagnosis of Asherman's syndrome is primarily based on:

1. Clinical history: Menstrual abnormalities following uterine procedures 2
2. Imaging studies:
   • Saline infusion sonography (SIS)
   • Hysterosalpingogram (HSG)
   • MRI in select cases 2
3. Hysteroscopy: The gold standard for definitive diagnosis and treatment 5

Treatment Approaches

The management of Asherman's syndrome involves:

1. Hysteroscopic adhesiolysis: Surgical removal of adhesions, preferably using miniature scissors 5
2. Prevention of adhesion reformation:
   • Placement of a balloon stent immediately after surgery 5
   • Hormonal therapy with estrogen to stimulate endometrial regrowth 5
3. Emerging therapies:
   • Mesenchymal stem cells (MSCs) therapy: Shows promise in restoring endometrial function through angiogenic, antifibrotic, and anti-inflammatory properties 6
   • Exosome therapy: May promote tissue repair and reduce fibrosis 6

Pregnancy Outcomes and Complications

Women with a history of Asherman's syndrome who become pregnant require careful monitoring due to increased risks of:

• Placenta accreta spectrum: The risk increases significantly with prior endometrial damage 3
• Cervical incompetence: May require cervical cerclage 5
• Intrauterine growth restriction: Requires close fetal monitoring 5

Prevention

Prevention of Asherman's syndrome is crucial and includes:

• Avoiding unnecessary uterine curettage
• Using gentle techniques during intrauterine procedures
• Early recognition and treatment of postpartum or post-abortion infections
• Considering hysteroscopic guidance for intrauterine procedures in high-risk patients

Damage to the endometrium represents a significant risk factor not only for Asherman's syndrome but also for other serious conditions like placenta accreta spectrum, highlighting the importance of endometrial preservation during gynecological procedures.