Asherman syndrome

Description

Rare, acquired clinical syndrome presenting with amenorrhoea, menstrual disorders and reproductive dysfunction secondary to intrauterine adhesions. [aka Fritsch syndrome; uterine atresia; amenorrhea traumatica; endometrial sclerosis; intrauterine adhesions; intrauterine synechiae]

History of Asherman syndrome

1894 – German obstetrician and gynecologist Heinrich Fritsch (1844–1915) provided the first description of a case of post-traumatic intrauterine adhesions

1927 – Bass reported about 20 cases of cases of atresia of the internal os in 1500 patients who had undergone induced termination of pregnancy in a Russian Hospital. Cyclic pain and amenorrhea disappeared spontaneously or after instrumental sounding of the cervix.

1946 – Stamer published on 24 cases with intrauterine adhesions associated with gravid uterus. He reviewed the literature and highlighted 17 individual case reports (between 1894-1933) and cited the 20 cases reported by Bass in 1927.

In the Gynecological Dep. I of the Rigshospital, during the past two years we have seen 24 patients with atresia of the uterus, in all of whom this phenomenon appeared after excochleation following parturition or abortion.

The puerperal state of the uterus implies decisively a disposition to atresia…and the writer advises strongly against energetic excochleation, particularly against the employment of a sharp curette for excochleation of the puerperal uterus.

Stamer 1946

1948 – Asherman described 29 cases he termed ‘amenorrhea traumatica‘ treated between 1944 and 1946, in the Journal of Obstetrics and Gynecology of the British Empire. He acknowledged the work of Stamer and ther previous case reports.

This pathological reaction of the uterus is the outcome of a graver injury than usual, such as repeated or deep curettage for missed abortion…or as a result of a normal or even very slight injury when the uterus has been harmed by large-scale haemorrhage

Asherman’s cases suffered obliteration of the endometrial cavity with amenorrhea ranging from 3-12 months. Treatment involved the passage of a uterine sound through the internal os and dilatation which restored some degree of menstruation in 27/29 cases, with 10 achieving subsequent pregnancy. Asherman initially felt that the stenosis was due to muscular contraction

In our opinion, under certain conditions, the uterus reacts to curettage by tetanic contractions, which may pass after a few moments or hours, but may also continue so long as to become permanent. The contraction of the circular muscles round the uterine os, causes the os to narrow at the close of any abrasion. In the cases under consideration here, prolonged spastic stricture becomes organic in the course of time.

Asherman 1948

1950 – Asherman followed his original article with a description of ‘traumatic intrauterine adhesions.’ Asherman collected 65 cases between 1848-1850, evaluated by hysterosalpingography. He presented evidence that curettage or packing of the post-termination or postpartum uterus could induce formation of synechiae within the body of the uterus and advocated hysterotomy, hysteroscopy and digital breakdown of the adhesions as treatment.

Also, hysteroscopy, which has so often been mentioned in the literature and just as often discarded, may perhaps be of use for this purpose. If it were possible to see the adhesions and to loosen them instrumentally, using the eye as a guide, the ideal method would have been found

Asherman 1950

1962 – Paul T. Topkins of Brooklyn, New York used the term Asherman syndrome in his review of traumatic intrauterine synechiae in the American Journal of Obstetrics and Gynecology. He concluded that the “Asherman syndrome occurs characteristically after one or more curettages of the pregnant or recently pregnant uterus”

1988 – The American Fertility Society developed an objective scoring system for classification of intrauterine adhesions that correlated the menstrual history with hysteroscopic and hysterosalpingographic findings

Associated Persons

• Heinrich Fritsch (1844 – 1915)
• Joseph G. Asherman (1889 – 1968)

References

Historical references

• Asherman JG. Amenorrhoea traumatica (atretica). The Journal of Obstetrics and Gynæcology of the British Empire 1948; 55: 23–30.
• Asherman JG. Traumatic intra-uterine adhesions. The Journal of Obstetrics and Gynæcology of the British Empire 1950; 57: 892–6.

Eponymous term review

• Fritsch H. Ein Fall von volligem Schwaund der Gebormutterhohle nach Auskratzung [A case of complete disappearance of the uterine cavity after extraction]. Zentralblatt für Gynäkologie. 1894; 18: 52–54.
• Bass B. Ueber die Verwachsungen in der cervix uterinach curettagen. Zentralblatt für Gynäkologie 1927; 51: 223.
• Stamer S. Partial and total atresia of the uterus after excochleation. Acta Obstet Gynecol Scand 1946; 26(2): 263-297.
• Topkins PT. Traumatic intrauterine synechiae. The Asherman syndrome. Am J Obstet Gynecol. 1962 Jun 15;83:1599-608.
• The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions. Fertil Steril. 1988 Jun;49(6):944-55.
• Nasr AL, Al-Inany HG, Thabet SM, Aboulghar M. A clinicohysteroscopic scoring system of intrauterine adhesions. Gynecol Obstet Invest. 2000;50(3):178-81.
• Berman JM. Intrauterine adhesions. Semin Reprod Med. 2008 Jul;26(4):349-55.
• Yu D, Wong YM, Cheong Y, Xia E, Li TC. Asherman syndrome–one century later. Fertil Steril. 2008 Apr;89(4):759-79