What is the treatment for Asherman's syndrome?

Treatment of Asherman's Syndrome

The standard treatment for Asherman's syndrome is hysteroscopic adhesiolysis followed by measures to prevent adhesion reformation, including placement of a balloon stent and postoperative estrogen therapy. This approach offers the best outcomes for restoring normal uterine anatomy and function 1, 2.

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Primary diagnostic tools:

  • Saline sonohysterography (most sensitive initial screening)
  • Hysterosalpingography (useful for initial diagnosis)
  • Hysteroscopy (gold standard for definitive diagnosis and treatment)
  • MRI (required only for completely obliterated uterine cavities) 3

• Clinical presentation:

  • Amenorrhea or hypomenorrhea (most common)
  • Normal menses in up to 25% of cases
  • Cyclic pelvic pain (due to outflow obstruction)
  • Infertility or recurrent pregnancy loss 1

Treatment Algorithm

1. Surgical Management

• Hysteroscopic adhesiolysis:
  • Use of miniature scissors is most efficacious for dividing adhesions 1
  • Work from central part of uterus to periphery 3
  • Power instruments, electrosurgery, or laser may be used in selected cases
  • Peroperative ultrasonography helps prevent complications in outpatient settings
  • Hysteroscopy with fluoroscopy for difficult cases 3

2. Prevention of Adhesion Reformation

• Immediate post-surgical interventions:

  • Placement of a balloon stent inside the uterus (most effective method) 1
  • Alternative: Intrauterine device (IUD) placement 3
  • Duration: Typically 7-10 days

• Hormonal therapy:

  • High-dose estrogen therapy to stimulate endometrial regrowth 1
  • Common regimen: Conjugated estrogens 2.5mg daily or estradiol valerate 2mg twice daily for 30-60 days
  • Add cyclic progestin in the last 10 days of treatment to induce withdrawal bleeding

3. Follow-up and Monitoring

• Post-treatment evaluation:

  • Second-look hysteroscopy 2-3 months after initial procedure
  • Mandatory follow-up studies to confirm resolution before attempting conception 1

• Pregnancy monitoring:

  • Careful surveillance for:
    • Cervical incompetence
    • Placenta accreta
    • Intrauterine growth restriction 1

Advanced and Emerging Treatments

For severe cases or recurrent adhesions:

• Regenerative approaches:

  • Stem cell therapy to restore endometrial function 4, 2
  • Platelet-rich plasma for endometrial regeneration 2

• Combined approaches:

  • Integrated hormonal and cellular therapies to restore adequate endometrial thickness 4

Prognosis and Outcomes

• Menstrual function: Most patients can achieve restoration of normal menses
• Fertility outcomes: Variable, with lower pregnancy rates in severe cases
• Complications: Higher risk of obstetric complications, especially with higher-grade disease 2

Important Caveats

• Severity of adhesions significantly impacts treatment success and prognosis
• Patients with dense, fibrotic adhesions or completely obscured uterine fundus present the greatest therapeutic challenge 5
• Referral to specialists with expertise in treating Asherman's syndrome is crucial for optimal outcomes 2
• Prevention is critical - minimize unnecessary instrumentation of the gravid uterus 2

The treatment approach should be tailored based on the extent and severity of adhesions, with comprehensive follow-up to ensure complete resolution before attempting conception.