What is Asherman's Syndrome?
Asherman's syndrome is an acquired uterine condition characterized by intrauterine adhesions (scar tissue) and fibrotic changes within the uterine cavity that cause menstrual abnormalities, pelvic pain, and infertility. 1
Clinical Definition and Pathophysiology
Asherman's syndrome results from the obliteration of the uterine cavity caused by partial or complete fibrous intrauterine adhesions, typically involving at least two-thirds of the uterine cavity and potentially obstructing the internal cervical orifice. 2 The condition develops when the basal layer of the endometrium is damaged, affecting the endometrial stem cell niche and leading to abnormal healing with scar tissue formation rather than normal endometrial regeneration. 3
Etiology and Risk Factors
The primary cause is iatrogenic trauma to the pregnant uterus, most commonly from curettage procedures (such as dilation and curettage for miscarriage or postpartum hemorrhage). 1, 4
Other causes include:
- Hysteroscopic surgery complications 5
- Uterine artery embolization 5
- Uterine tuberculosis 5
- Congenital uterine abnormalities 3
- Idiopathic cases without prior surgical procedures, suggesting possible genetic predisposition 3
Women who develop Asherman's syndrome in the puerperal period (postpartum) have significantly worse outcomes than those who develop it outside this period, with an 86.3% adhesion reformation rate versus 38.6% in non-puerperal cases. 6
Clinical Presentation
The classic triad of symptoms includes:
Obstetrical Complications
Asherman's syndrome causes significant obstetrical challenges even after treatment, including:
- Recurrent pregnancy loss 1
- Placental abnormalities (including placenta accreta) 1, 7
- Preterm birth 1
- Intrauterine growth retardation 1
These complications are worse in patients with higher grades of disease. 4
Diagnostic Approach
Hysteroscopy is the gold standard for definitive diagnosis of Asherman's syndrome. 2, 5
For initial screening, less invasive modalities include:
- 3-D ultrasound: 100% sensitive for grading intrauterine adhesions compared to hysteroscopy 8
- Sonohysterography (SIS): 100% sensitive in one study, with 75% sensitivity and 93% specificity in another study 8
- Hysterosalpingography (HSG): Only 66.7% sensitive for grading adhesions and 75-81% sensitive for detecting adhesions 8
- Conventional transvaginal ultrasound: Only 52% sensitive 8
Magnetic resonance imaging is required when the uterine cavity is totally obliterated. 5
Treatment
Hysteroscopic adhesiolysis (surgical division of adhesions) represents the current gold standard treatment. 1, 2 The procedure involves dividing intrauterine adhesions with scissors or power instruments, working from the central part of the uterus to the periphery. 5
Peroperative ultrasonography is useful in outpatient settings to prevent complications, while hysteroscopy with fluoroscopy is recommended for difficult cases. 5
Post-Surgical Management
Intrauterine devices such as balloon catheters or intrauterine contraceptive devices are the preferred methods for preventing adhesion recurrence after treatment. 5
Emerging Therapies
Autologous CD133+ bone marrow-derived stem cell therapy has been designated as an Orphan Drug by the EMA and FDA for Asherman's syndrome treatment. 7 A phase 1/2 trial demonstrated this therapy was well tolerated with no treatment-related serious adverse events, showing promise for moderate to severe cases unresponsive to prior hysteroscopic treatments. 7
Other investigational approaches include:
- Platelet-rich plasma for endometrial regeneration 4
- Tissue-engineered scaffolds 1
- Paracrine-acting factors 1
Prognosis
Most patients can achieve restoration of menstrual function; however, lower pregnancy rates and obstetric complications remain common. 4 The adhesion reformation rate is substantial, with outcomes significantly worse for puerperal cases and higher-grade disease. 6