Asherman's syndrome

Description:

Intrauterine synechias represent the connective tissue unions which are accustoming to drinking among themselves walls of a uterus and causing its deformation. In the presence of synechias the normal endometria is exposed to atrophic transformation. Intrauterine synechias lead to disorder of menstrual function, create mechanical obstacles for advance of spermatozoa, worsen conditions for implantation of fetal egg. From here the main manifestations of a syndrome of Asherman – a hypomenorrhea, a secondary amenorrhea, misbirths, infertility follow.

Reasons of a syndrome of Asherman:

There are several theories of emergence of intrauterine synechias — infectious, traumatic and neurovisceral. However a major factor of fusion of a uterus the mechanical injury of a mucous membrane after the delivery or abortion, and an infection already secondary factor is considered.

The most probable emergence of intrauterine synechias at women with the stood pregnancy. It is connected with the fact that after a scraping of a cavity of the uterus the remains of a placenta can cause activation of fibroblasts (connective tissue cell) and formation of collagen before recovery of a mucous membrane.

Intrauterine synechias can also arise at 5-40% of women with repeated abortions, after uterus operations (myomectomies, metroplasty, a scraping of a mucous membrane of a uterus for diagnosis, conization of a neck of uterus. This pathology also the endometritis or an intrauterine contraceptive can provoke.

Symptoms of a syndrome of Asherman:

Depending on degree of manifestation of intrauterine synechias the hypomenstrual molimina or a secondary amenorrhea can develop. At an obliteration of lower parts of a uterus at functional safety of an endometria in her upper parts, formation of a gematometra can be noted.
Much the expressed intrauterine commissures at a lack of the functioning endometria interfere with implantation of fetal egg; the obliteration of pipes makes impossible fertilization process. Therefore intrauterine synechias often are followed by not incubation of pregnancy or infertility. Besides, even existence of poorly expressed intrauterine synechias becomes frequent the reason of inefficiency of extracorporal fertilization.

Classification:

As a histologic structure allocate 3 groups of intrauterine synechias. Film unions usually consist of cells of a basal endometria, easily give in to a section a tip of the hysteroscope and correspond to an easy form of a syndrome of Asherman. At average degree intrauterine synechias fibromuscular, are strong soldered to an endometria, at a section bleed. The severe form of a syndrome of Asherman is characterized by dense, connective tissue intrauterine synechias which hardly move to a section.
On degree of an involvement of a cavity of the uterus and prevalence of intrauterine synechias allocate 3 degrees of a syndrome of Asherman. At the I degree less than 25% of a cavity of the uterus, a synechia thin are involved in pathological process, do not extend to an uterine fundus and mouths of pipes. At the II degree of a disease of a synechia borrow from 25% to 75% of a cavity of the uterus, adhesion of walls is absent, the partial obliteration of a bottom and the mouth of uterine tubes is noted. The III degrees of a syndrome of Asherman there corresponds involvement practically to all cavity of the uterus (> 75%).
The operational gynecology uses the international European classification of Association of gynecologists-endoscopists according to which five degrees of intrauterine pathology are allocated. These hysteroscopies and gisterografiya considering a condition of intrauterine synechias, their extent, existence of occlusion in mouths of pipes, an endometria damage rate are the basis for classification.
The first degree of a syndrome of Asherman is characterized by existence of thin and gentle intrauterine synechias which easily collapse at contact, free mouths of fallopian pipes.
At the second degree of a syndrome of Asherman the dense single commissure connecting the isolated parts of a cavity of the uterus comes to light; the synechia does not collapse at contact with the end of the hysteroscope; mouths of uterine tubes are looked through. The option of localization of synechias in a zone of an internal uterine pharynx at not changed upper parts of a cavity of the uterus is possible.
To the third degree of a syndrome of Asherman there corresponds existence of the dense multiple synechias connecting separate parts of a cavity of the uterus, and a unilateral obliteration of the mouth of a uterine tube.
At the fourth degree of a syndrome of Asherman dense extensive intrauterine synechias, partial occlusion of a cavity of the uterus and mouths of both pipes come to light.
The fifth degree combines extensive processes of fibrosing and scarring of an endometria with the phenomena of I or II, III or IV degrees of a syndrome of Asherman, and also a hypomenorrhea or an amenorrhea.

Diagnosis:

The correct diagnosis about a condition of an intrauterine cavity requires carrying out full inspection which includes an interview with the patient, collection of information about the anamnesis allowing to establish an origin of disturbances in a uterus. Besides, transvaginal ultrasonic examination, diagnostic hysteroscopy and a gisterosalpingografiya are conducted.

Transvaginal ultrasonography allows to be hit the image of a uterus by input in a vagina of the ultrasonic sensor. Usually the research is conducted in the gynecologist's office. At suspicion on Asherman's syndrome it is necessary to define a condition of an endometria at various moments of a cycle as in places of emergence of synechias there is a pathological growth of a mucous membrane. Three-dimensional ultrasonography provides additional information and excludes other pathologies.

Diagnostic hysteroscopy allows to consider better commissures, to learn extent of their growth, to define a condition of a cavity, to see openings of uterine tubes, to define real opportunities of treatment and to make the real forecast of results depending on complexity of each case. It is a simple diagnostic method which does not demand the general anesthesia and which by means of physiological serum gives the chance to inspect an internal part of a uterus and to see the image on the monitor screen. The procedure becomes on an outpatient basis.
Gisterosalpingografiya provides less information, than diagnostic hysteroscopy therefore it is used less often.

After diagnosis of a syndrome of Asherman it is necessary to define how the disease affects a clinical condition of the patient. That is it is necessary to learn whether the woman wants to become pregnant and if she does not manage it whether the repeating abortions or disturbances of implantation took place, or the syndrome led only to reduction of menstrual allocations. All this helps to choose the correct method of treatment.

Treatment of a syndrome of Asherman:

As the purpose of medical actions at Asherman's syndrome serves low-traumatic elimination of intrauterine unions, recovery of normal menstrual function and fertility.
At intrauterine synechias the first stage showed carrying out operational hysteroscopy for the purpose of an adhesiotomy under direct vision. Division of synechias depending on their density is made by the hysteroscope case, endoscopic scissors, nippers, gisterorezektoskopy, the laser. For an exception of perforation of a uterus control by means of ultrasonography or a laparoscopy is used.
After an operational stage to the patient with Asherman's syndrome the cyclic hormonal therapy estrogen and gestagena directed to stimulation of recovery of an endometria and its cyclic transformation is appointed. Purpose of the combined oral contraception at intrauterine synechias is excluded as this group of drugs promotes atrophic changes of an endometria.
At an infectious etiology of a syndrome of Asherman the bacteriological research of smears and materials of a vacuum biopsy is made, antibacterial therapy is carried out.