Total obstructive Asherman syndrome

Specialty: Gynecology and breast.

• Complete intrauterine synechiae
• total obliteration of the uterine cavity
• post-curettage obstructive amenorrhea

Why it occurs

• Massive destruction of the basal layer of the endometrium after repeated curettage or forceful curettage performed in the presence of active uterine infection
• Untreated severe tuberculous endometritis
• Previous thermal or radiofrequency surgical endometrial ablation

Initial workup

High-resolution transvaginal ultrasound (shows absence of endometrial line in the luteal phase or an interrupted line with a unstructured appearance). Outpatient diagnostic hysteroscopy (absolute reference pattern that shows partial or total obliteration of the uterine cavity by dense whitish fibrous adhesions that prevent the tubal ostia from being seen). Pelvic MRI if the uterine cavity is completely obliterated and initial hysteroscopic access is not possible.

Standard management

• There are no drugs that resolve fibrous fusion of the uterine walls. The treatment of choice consists of careful sectioning of the synechiae using surgical hysteroscopy under direct vision (adhesiolysis with microscissors or cold energy to avoid further thermal damage). Postoperatively, conjugated equine estrogens 1.25-2.5 mg/day orally or estradiol valerate 4-6 mg/day are prescribed for 60 days to induce endometrial regeneration, associating medroxyprogesterone acetate 10 mg/day the last 10 days of each month (note: the temporary insertion of an intrauterine balloon or a Lippes loop IUD is usually required to keep the the uterine walls during the epithelialization phase).