Uterine Synechiae

Uterine Synechiae is a topic covered in the 5-Minute Clinical Consult.

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Basics

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

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