What are the clinical presentation, diagnostic approach, and treatment options for uterine synechiae (Asherman syndrome)?

Uterine Synechiae (Asherman Syndrome)

Clinical Presentation

Uterine synechiae (Asherman syndrome) classically presents with the triad of menstrual abnormalities (hypomenorrhea to amenorrhea), infertility, and cyclic pelvic pain, most commonly developing after instrumentation of a pregnant or recently pregnant uterus. 1, 2, 3

Key Clinical Features to Identify:

• Menstrual pattern changes: Progressive decrease in menstrual flow leading to amenorrhea in severe cases 2, 4
• Infertility or recurrent pregnancy loss: Occurs due to inadequate endometrial surface area for implantation 1, 2
• Cyclic pelvic pain: Results from obstructed menstrual flow when the internal cervical os is involved 2
• History of uterine trauma: Most critical risk factor to elicit 1, 3

Specific Etiologic Factors to Document:

• Pregnancy-related curettage (most common): Postpartum hemorrhage (37.5%), incomplete abortion (33.3%), elective abortion (8.3%) 1
• Cesarean section: Less common but increasingly recognized cause 1
• Hysteroscopic procedures: Myomectomy, septum resection, endometrial ablation 1, 5
• Postpartum transarterial embolization: Carries up to 12% risk of synechiae formation 6

Diagnostic Approach

Hysteroscopy is the gold standard for both diagnosis and treatment of Asherman syndrome, allowing direct visualization, grading of adhesions, and immediate therapeutic intervention. 2, 4, 5, 3

Recommended Diagnostic Algorithm:

Initial imaging:

• 3-D ultrasound: First-line imaging modality with 100% sensitivity for grading intrauterine adhesions compared to hysteroscopy 6, 7
• Saline infusion sonohysterography (SIS): Alternative with 100% sensitivity for detecting intrauterine adhesions 6
• Conventional transvaginal ultrasound: Only 52% sensitive; inadequate as sole diagnostic tool 6

Avoid common diagnostic pitfalls:

• Do not rely on HSG alone: Only 66.7% sensitive for grading adhesions and 75-81% sensitive for detection 6
• HSG shows irregular endometrial filling defects but cannot adequately characterize severity 6
• MRI has limited data for intrauterine adhesions with no large comparative studies to hysteroscopy 6

Definitive diagnosis:

• Hysteroscopy: Provides direct visualization, allows classification of severity (mild/moderate/severe based on extent of cavity involvement and cervical os obstruction), and enables immediate treatment 2, 4, 5, 3

Treatment Options

Hysteroscopic adhesiolysis is the primary treatment, requiring an integrated approach with preoperative preparation, careful surgical technique, and postoperative measures to prevent adhesion reformation. 2, 4, 5, 3

Surgical Management:

Hysteroscopic lysis of adhesions:

• Operative hysteroscopy is the mainstay of treatment for restoring uterine cavity anatomy 4, 5
• Significantly obliterated cavities may require multiple procedures to achieve satisfactory anatomical and functional results 5
• Selective hysteroscopic removal of retained tissue is preferred over blind curettage to prevent adhesion formation 5

Postoperative Measures to Prevent Recurrence:

While no consensus exists on the ideal method, several adjunctive therapies are used 2, 3:

• Intrauterine device or balloon placement: Maintains cavity separation during healing 2, 4
• Estrogen therapy: Promotes endometrial regeneration 2, 4
• Antibiotic prophylaxis: Consider if infection risk factors present 6
• Second-look hysteroscopy: Assess for adhesion reformation 2, 4

Emerging Therapies:

• Stem cells and platelet-rich plasma: Being explored for endometrial regeneration but data remain limited 3

Expected Outcomes and Prognosis

Most patients achieve restoration of menstrual function after treatment, but pregnancy rates remain lower than normal and obstetric complications are common, particularly with higher-grade disease. 3

Realistic Outcome Expectations:

• Menstrual function: Successfully restored in most cases 3
• Pregnancy rates: Lower than baseline population, worse with severe disease 3
• Recurrence risk: Up to 44% experience symptom recurrence within 12 months after treatment 8, 9
• Obstetric complications: Increased risk of placental abnormalities, preterm delivery 1, 3

Critical Prevention Strategy:

The most effective approach is prevention through minimizing uterine instrumentation of the gravid uterus and using selective hysteroscopic techniques rather than blind curettage when intervention is necessary. 5, 3