Description

• Uterine synechiae are intrauterine adhesions (IUAs).
• Symptoms may include menstrual disturbance (amenorrhea, hypomenorrhea, or dysmenorrhea), pelvic pain, recurrent spontaneous abortions (SABs), and/or infertility in a female of childbearing age.
• When specific signs or symptoms are associated with the presence of IUAs, it is called Asherman syndrome.
• IUAs can also be present in the absence of symptoms: asymptomatic IUAs.
• Severity of symptoms ranges from mild to moderate to severe, depending on the degree of adhesions (e.g., number, density, thickness, quality).
• There are seven different classification systems to categorize disease severity.
  • Important to classify severity because it has prognostic value for fertility (1)[C]
  • Each system includes consideration of adhesion characteristics on hysteroscopy.
  • Currently, no single uniform system is endorsed, thus difficult to compare studies.

Epidemiology

Incidence
1.5% of all hysterosalpingographies

Prevalence

• Varies with geography, population profile, availability of diagnostic devices
• Asymptomatic population: 0.3% incidental finding of uterine adhesions
• After postpartum curettage: 22%
• After postabortion curettage: 37%

Etiology and Pathophysiology

• Endometrial injury stimulates fibrosis. See “Risk Factors” for specific types of injury.
• Fibrous tissue replaces endometrial stroma and glands; replacing normal, vascular tissue with denser, less vascular tissue
• Eventually, endometrial lining becomes atrophic and inert.

Risk Factors

• 90% of cases result from curettage such as:
  • Diagnostic curettage
  • Postabortion curettage
  • Postpartum curettage especially >48 hours postpartum
• Other risk factors include the following:
  • Cesarean section
  • Pelvic radiation
  • Polypectomy
  • Intrauterine device (IUD) insertion
  • Myomectomy
  • Postpartum hemorrhage
  • Recurrent SABs
  • Pelvic infection (e.g., endometrial tuberculosis or pelvic inflammatory disease)—controversial

General Prevention

• Minimize intrauterine operative interventions while women are fertile and desire pregnancy.
• Expectant or medical management rather than surgical management of SABs