Asherman syndrome, also known as uterine synechiae, is a condition characterised by the formation of intrauterine adhesions, which are usually sequela from injury to the endometrium, and is often associated with infertility.
There is a tendency for the condition to develop soon after pregnancy (usually within four months 9). The incidence is thought to be increasing probably as a result of increased use of intrauterine interventions.
Patients may present with infertility, pregnancy loss, menstrual abnormalities (e.g. amenorrhoea, hypomenorrhoea, dysmenorrhoea) or abdominal pain 1.
Intrauterine adhesions result secondary to trauma to the basal layer of the endometrium with subsequent scarring 1. This may be from previous pregnancy, dilation and curettage, surgery, or infection (e.g. genital tuberculosis).
The adhesions are composed of fibromuscular-connective tissue bands with or without surrounding superficial epithelial cells or glandular tissue.
Intrauterine adhesions are typically seen on HSG as multiple irregular linear filling defects (may give a lacunar pattern), with the inability to appropriately distend the endometrial cavity 2. In severe cases, there can even be complete non-filling of the uterine cavity.
May be seen as bands traversing through the endometrial cavity. Sonohysterography can demonstrate hyperechoic band adhesions across the uterine cavity 10.
The adhesions are usually low signal on T2.
Treatment and prognosis
The goal of therapy is to remove adhesions and subsequently restore the normal size and shape of the uterine cavity. This is most commonly done by lysis of adhesions via hysteroscopy 3. The reproductive outcome correlates with the type of adhesions and extent of uterine cavity occlusion.
History and etymology
The condition was Initially described by Joseph Asherman in 1948 9.
On a hysterosalpingogram consider:
- normal intrauterine longitudinal folds in a non-distended uterus may sometimes mimic uterine synechiae 4
- 1. Klein SM, García CR. Asherman's syndrome: a critique and current review. Fertil. Steril. 1973;24 (9): 722-35. - Pubmed citation
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- 4. Steinkeler JA, Woodfield CA, Lazarus E et-al. Female infertility: a systematic approach to radiologic imaging and diagnosis. Radiographics. 29 (5): 1353-70. doi:10.1148/rg.295095047 - Pubmed citation
- 4. Ball RH, Buchmeier SE, Longnecker M. Clinical significance of sonographically detected uterine synechiae in pregnant patients. J Ultrasound Med. 1997;16 (7): 465-9. J Ultrasound Med (abstract) - Pubmed citation
- 6. Letterie GS, Haggerty MF. Magnetic resonance imaging of intrauterine synechiae. Gynecol. Obstet. Invest. 1994;37 (1): 66-8. - Pubmed citation
- 7. Bacelar AC, Wilcock D, Powell M et-al. The value of MRI in the assessment of traumatic intra-uterine adhesions (Asherman's syndrome). Clin Radiol. 1995;50 (2): 80-3. - Pubmed citation
- 8. March CM. Intrauterine adhesions. Obstet. Gynecol. Clin. North Am. 1995;22 (3): 491-505. - Pubmed citation
- 9. Berman JM. Intrauterine adhesions. Semin. Reprod. Med. 2008;26 (4): 349-55. doi:10.1055/s-0028-1082393 - Pubmed citation
- 10. Gupta A, Desai A, Bhatt S. Imaging of the Endometrium: Physiologic Changes and Diseases: Women's Imaging. (2017) Radiographics : a review publication of the Radiological Society of North America, Inc. 37 (7): 2206-2207