Uterine Synechiae

Uterine synechiae are intrauterine adhesions, fibrous bands that partly or completely obliterate the uterine cavity or cervical canal. With symptoms they form Asherman syndrome.

• A common cause is trauma to the basal endometrium from curettage after miscarriage, abortion or postpartum haemorrhage.
• Infection, especially genital tuberculosis and schistosomiasis, is a cause in Africa.
• Treatment is hysteroscopic adhesiolysis with measures to prevent recurrence.

Light, absent or painful periods, secondary amenorrhoea, infertility, recurrent miscarriage and cyclical pelvic pain.

• Cervical stenosis, haematometra, or normal examination.
• Differential diagnosis: cervical stenosis, premature ovarian insufficiency, polycystic ovary syndrome, hypothalamic amenorrhoea, pregnancy, hyperprolactinaemia, endometrial polyp.
• Complications: infertility, miscarriage, preterm birth, placenta accreta spectrum, abnormal placentation and recurrent adhesions.

Diagnosis is by hysteroscopy, after exclusion of other causes of amenorrhoea.

• Pregnancy test, FSH, LH, prolactin and thyroid function to exclude other causes of amenorrhoea.
• Hysteroscopy (diagnostic standard) showing bands and cavity obliteration.
• Hysterosalpingography, saline infusion sonography or three-dimensional ultrasound where hysteroscopy is not available.
• Xpert MTB/RIF or endometrial biopsy for tuberculosis; urine or biopsy for schistosomiasis in endemic areas.

Divide the adhesions hysteroscopically and prevent recurrence with a physical barrier and oestrogen.

• Supportive: counselling on the chance of conception and need for early antenatal care in the next pregnancy.
• Pharmacological: antibiotic cover at surgery: doxycycline 100 mg oral 12-hourly for 5 to 7 days, or ceftriaxone 1 g IV single dose. After adhesiolysis give oestradiol valerate 2 mg oral 12-hourly for 30 to 60 days with medroxyprogesterone acetate 10 mg oral daily for the last 10 days of oestrogen to bring on withdrawal bleeding. Genital tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg and ethambutol 15 mg/kg, all oral once daily for 2 months, then isoniazid and rifampicin once daily for 4 months, with pyridoxine 25 mg oral daily. Schistosomiasis: praziquantel 40 mg/kg oral single dose.
• Procedures: hysteroscopic adhesiolysis under ultrasound or laparoscopic guidance, with scissors (not diathermy where possible), to restore the cavity and tubal ostia. Place a Foley catheter with 3 mL balloon in the cavity for 7 to 10 days, or an intrauterine device, to prevent recurrence. Second-look hysteroscopy 4 to 8 weeks later, with repeat adhesiolysis as needed.
• Special groups: in women with venous thromboembolism or oestrogen-sensitive cancer avoid oestrogen therapy. In liver impairment monitor liver enzymes on tuberculosis drugs. In pregnancy after treatment, book early, scan for placenta accreta and plan delivery in a facility with blood.
• Red flags: haematometra with pain, uterine perforation at surgery, fever after surgery, severe adhesions with no cavity.
• Follow-up: review at 2 and 4 to 8 weeks; confirm menses resumption; try to conceive within 6 months after a normal cavity.