Restrictive uterine synechiae

Specialty: Gynecology and breast.

• Asherman syndrome
• intrauterine adhesions
• post-curettage obstructive hypomenorrhea
• obliteration of the uterine cavity

Why it occurs

• Abnormal healing and fusion of the endometrial walls after vigorous instrumental uterine curettage performed for abortions or postpartum hemorrhages (most common cause)
• Previous intrauterine surgical procedures (myomectomy, polypectomy or septal resection by hysteroscopy)
• Tuberculous endometritis (genital tuberculosis that destroys the basal layer of the endometrium, common in endemic areas)

Initial workup

Hysterosalpingography (HSG) that detects characteristic lacunar filling defects within the uterine cavity. Three-dimensional (3D) transvaginal ultrasound or ultrasound with saline instillation (sonohysterography). Diagnostic hysteroscopy in consultation (gold standard that allows confirming the presence, location, extension and severity of intrauterine flanges or synechiae).

Standard management

• There is no direct pharmacological treatment to dissolve intrauterine fibrous adhesions. The treatment of choice consists of sectioning the flanges using surgical hysteroscopy (hysteroscopic adhesiolysis). After the intervention, estradiol valerate 2-4 mg orally per day is prescribed for 30 to 60 days to promote rapid re-epithelialization of the endometrium, combining Medroxyprogesterone acetate 10 mg/day for the last 10 days to induce withdrawal bleeding (note: temporary placement of a pediatric intrauterine Foley catheter or a specific catheter may be required to prevent recurrence of adhesions).