Intrauterine Adhesions

Intrauterine Adhesions

Intrauterine adhesions are formed when there is an injury or a cut on the endometrium (the lining of the womb which sheds off with every cycle at menstruation) that does not heal properly and forms scar tissue, which is also called an adhesion(s). These adhesions replace the normal endometrial lining and can cause a reduction in menstrual flow and difficulty getting pregnant because the fertilized egg is unable to implant on the abnormal endometrium. It also causes the walls of the uterus to stick together and distorts the shape of the cavity, or forms a ‘band’ that can block the cavity. It is sometimes referred to as Asherman’s syndrome.

Intrauterine adhesions usually occur after any procedure that can cause injury or damage to the endometrium, irrespective of the reason for which the procedure was done. This includes the following:

  • Dilatation and Curettage (D&C)
  • Manual Vacuum Aspiration (MVA)
  • Caesarean section
  • Open myomectomy
  • Hysteroscopic surgeries
  • Manual removal of the placenta

Intrauterine adhesions commonly cause the following symptoms:

  • Reduction in the amount of bleeding during menstruation
  • Reduction in the number of days of menstruation
  • Passing small amounts of dark blood during a period
  • Developing painful periods (dysmenorrhoea)
  • Recurrent early miscarriages
  • Difficulty in getting pregnant

It is possible to develop intrauterine adhesions after a procedure without having any of the symptoms described above.

After a review with the doctor, you will have an ultrasound scan done to examine the endometrial lining, but this may not be sufficient to confirm the diagnosis of intrauterine adhesions. A special type of scan called a sonohysterogram can be done; in which a thin tube is passed into the uterus from the vagina and used to introduce fluid into the cavity before the scan is done. This helps to make the scan images clearer. A hysterosalpingogram (HSG) can be done. Here, a dye is inserted into the uterus through the vagina, and then a series of X-rays are taken of the lower abdomen. A HSG outlines the uterine cavity, and can show if there is any distortion or blockage. The most accurate test that is done is an outpatient hysteroscopy. In this procedure, a fine instrument with a camera (a hysteroscope) is introduced into the vagina and it goes through the cervix to the uterus, while the images are projected on a screen. This allows for direct visualization of the cavity, so the extent of the adhesions can be seen clearly. It is a brief procedure that lasts for about 10 minutes.

Intrauterine adhesions are treated surgically, by a theatre procedure called a hysteroscopic adhesiolysis, which can be done either under spinal or general anaesthesia. A fluid is passed into the cavity of the uterus to enable insertion of a thin camera which has some cutting instruments attached to it. The images are projected on a screen, and the surgeon removes the scar tissue under direct visualization. The surgery lasts for about 30 minutes. After the procedure, there is usually a need to insert something into the uterus (either a Copper IUCD or a uterine balloon) to prevent the walls of the uterus from sticking together when healing is occurring, thus causing the adhesions to be re-formed inside the uterus. If this is done, whichever one that is inserted will be removed at a clinic visit, a few weeks after the surgery.

In moderate to severe cases, there is usually a need to take hormonal medications for a period of one to three months after the surgery, to encourage growth of the endometrium. Sometimes the procedure will need to be repeated once or twice before the cavity is restored to normal.