OVERVIEW

What is intrauterine adhesion?

Intrauterine adhesion (IUA), also known as Asherman's syndrome, is a condition caused by trauma to the uterine cavity that damages the basal layer of the endometrium, leading to partial or complete occlusion of the uterine cavity. This results in symptoms such as abnormal menstruation, infertility, or recurrent miscarriage. The essence of intrauterine adhesion is endometrial fibrosis.

Treatment primarily involves hysteroscopic surgery combined with medication. The surgery generally leaves no scars and has a good prognosis, but there is a certain risk of recurrence depending on the patient's condition.

What are the different types of intrauterine adhesion?

• By location: Simple cervical adhesion; Cervical and uterine cavity adhesion; Simple uterine cavity adhesion.

• By adhesion position: Central type; Peripheral type; Mixed type.

What are the harms of intrauterine adhesion?

• The most significant and primary harm is its impact on fertility. Intrauterine adhesion can lead to infertility and recurrent miscarriage.

• Other harms include cyclical lower abdominal pain, which affects normal life. Poor menstrual blood drainage reflexively stimulates uterine contractions, causing lower abdominal pain.

SYMPTOMS

What are the manifestations of intrauterine adhesions?

The main symptoms include changes in menstruation, such as scanty menstrual flow, amenorrhea, and dysmenorrhea.

The uterus is like a room, and the endometrium is like the wall paint in that room. Each month, menstruation is essentially the shedding of the endometrium, similar to replacing old wall paint in a room. Of course, new wall paint—or new endometrium—will grow back.

When the endometrium is damaged, intrauterine adhesions can occur. In mild cases, it's like cobwebs sticking to the walls of the room, while in severe cases, it's as if messy partitions appear in the room, dividing the uterus into separate cavities. This affects menstruation, leading to scanty flow or amenorrhea.

How is the severity of intrauterine adhesions classified?

• Based on the degree of adhesion, it can be divided into 5 levels:

  • Grade I: Multiple filmy adhesions in the uterine cavity, with normal uterine cornua and tubal ostia.

  • Grade II: Dense fibrous adhesions between the anterior and posterior uterine walls, with visible uterine cornua and tubal ostia.

  • Grade III: Fibrous adhesions causing partial occlusion of the uterine cavity and one uterine cornu.

  • Grade IV: Fibrous adhesions causing partial occlusion of the uterine cavity and both uterine cornua.

  • Grade Va: Scarring adhesions leading to severe distortion and narrowing of the uterine cavity.

  • Grade Vb: Scarring adhesions causing complete obliteration of the uterine cavity.

• Based on the extent of adhesions, they are classified as:

  • Mild: Less than 1/4 of the uterine cavity.

  • Moderate: More than 1/4 but less than 1/2 of the uterine cavity.

  • Severe: More than 1/2 of the uterine cavity.

Can the severity of intrauterine adhesions be judged by menstrual flow?

No.

Due to factors such as the location and extent of adhesions, patients with amenorrhea may only have mild adhesions, while those with scanty menstrual flow could already have severe adhesions.

The severity of intrauterine adhesions cannot be arbitrarily determined based on menstrual flow alone. It is important to seek medical attention promptly and follow the doctor's recommended treatment.

CAUSES

What Causes Intrauterine Adhesions?

Pregnancy-related factors account for 90% of intrauterine adhesions, while non-pregnancy factors make up the remaining 10%.

Pregnancy-related factors primarily include procedures such as post-abortion curettage (after induced, incomplete, or medical abortion), curettage following missed abortion, or postpartum curettage after mid-term or full-term delivery.

Non-pregnancy factors involve endometrial damage caused by infections or intrauterine surgical procedures, such as tuberculous endometritis, diagnostic curettage, myomectomy, submucosal fibroid removal, or hysteroscopic endometrial resection.

Additionally, uterine developmental abnormalities, low estrogen levels, and genetic factors are also associated with intrauterine adhesions.

DIAGNOSIS

Under what circumstances should one be vigilant about intrauterine adhesions and seek medical attention promptly?

If you have undergone any intrauterine procedures or have a history of miscarriage—whether medical abortion, surgical abortion, induced labor, or diagnostic curettage due to abnormal uterine bleeding—and experience a decrease in menstrual flow afterward, it is essential to see a doctor as soon as possible.

Early detection of intrauterine adhesions allows for timely and effective treatment, while delaying may lead to complications.

What tests are needed to diagnose intrauterine adhesions? What should be noted during the examination?

• Hysterosalpingography (HSG) is the first-line screening method for intrauterine adhesions. However, its accuracy is lower than hysteroscopy due to potential false-positive results caused by air bubbles, mucus, or endometrial fragments in the uterine cavity. This examination is generally painless but involves specific requirements, such as checking for allergies (especially to iodine), ensuring the procedure is performed 3–7 days after menstruation, and adhering to post-examination guidelines regarding sexual activity and conception timing. Follow your doctor's instructions carefully.

• Ultrasound is a simple, non-invasive method for diagnosing intrauterine adhesions. It evaluates the presence of intrauterine fluid, endometrial thickness and echo uniformity, endometrial continuity, and the clarity of the endometrial-myometrial junction. Transvaginal ultrasound is preferred for higher accuracy. Three-dimensional ultrasound can reconstruct uterine morphology and measure endometrial blood flow, further improving diagnostic precision.

• Hysteroscopy is the gold standard for diagnosing intrauterine adhesions. It allows direct visualization of the uterine cavity and enables minimally invasive surgical treatment under magnification. The procedure should not be performed during menstruation. Follow your doctor's specific instructions.

TREATMENT

Which department should I visit for intrauterine adhesions?

Gynecology, Obstetrics and Gynecology.

How should intrauterine adhesions be treated?

Hysteroscopic surgery combined with medication.

• Medications are usually hormones that promote endometrial growth, used as an adjunct to surgery to help the new endometrium regenerate quickly after the procedure.

• Surgery is performed using hysteroscopy and medical instruments. For patients with severe intrauterine adhesions, the procedure is highly challenging.

Is hysteroscopic surgery risky for patients with intrauterine adhesions?

For patients with moderate to severe intrauterine adhesions, the surgical risks are relatively high.

In the confined space of the uterine cavity, removing adhesions and excess tissue requires the use of instruments such as scissors, forceps, and electrocautery. Any slight error can easily lead to uterine perforation, making the operation extremely difficult. Therefore, the procedure is highly challenging.

It is essential to choose a qualified and experienced doctor and proceed with surgery under appropriate conditions based on the doctor's advice. For severe cases where surgery is not suitable, patients should follow the doctor's guidance and avoid insisting on the procedure.

Will hysteroscopic surgery leave scars for patients with intrauterine adhesions?

No.

Hysteroscopic surgery is minimally invasive and falls under NOTES (Natural Orifice Transluminal Endoscopic Surgery).

NOTES surgery is performed entirely through the body's natural orifice (the vagina), causing no external trauma or scarring. Such surgery is recommended when the doctor's skill level meets the requirements.

Can patients with intrauterine adhesions choose general anesthesia for hysteroscopic surgery?

Hysteroscopic surgery typically does not use general anesthesia but instead employs epidural or regional block anesthesia. This allows the doctor to monitor the patient's reactions and responses during the procedure, enabling early detection and management of any serious complications.

General anesthesia is usually chosen when combined with laparoscopic surgery.

Can intrauterine adhesions recur after surgery?

• It depends on the severity of the condition. For mild to moderate intrauterine adhesions, the recurrence rate after surgery is about 30%, while for severe cases, it can be as high as 60%.

• If the patient has undergone previous intrauterine adhesion surgery and experienced recurrence, the likelihood of recurrence after another surgery is usually very high.

DIET & LIFESTYLE

What should I pay attention to after intrauterine adhesion surgery?

Sexual intercourse should be avoided for one month after surgery to prevent infection. Eliminate all possible sources of infection and keep the perineal area clean and dry. Sexual activity can be fully resumed after one month.

To protect the fragile uterus post-surgery and prevent re-adhesion, doctors will place an intrauterine device (IUD). The IUD should be removed during a second examination as advised by the doctor.

After the IUD is removed, you should seize the opportunity to conceive as soon as possible. Delaying for too long may lead to recurrent intrauterine adhesions due to individual physiological factors.

What dietary precautions should patients with intrauterine adhesions take?

There are no specific dietary restrictions—maintaining a healthy, balanced diet is sufficient.

• Use less salt, oil, and high-sodium seasonings when cooking; avoid pickled vegetables and meats.

• Balance meat and vegetables, prioritizing white meats like chicken, duck, and fish over fatty meats. Eggs and milk are important sources of protein and other nutrients.

• Eat more fruits and vegetables.

• Avoid smoking and alcohol.

PREVENTION

How to Prevent Intrauterine Adhesions?

• Avoid abortions whenever possible, whether medical or surgical. Abortion is the leading cause of intrauterine adhesions, causing significant damage to the endometrium, especially with multiple procedures.

• Use contraception effectively. Condoms and oral contraceptives are reliable methods.

• Seek medical attention promptly. If experiencing reduced menstrual flow or amenorrhea, consult a doctor immediately, especially after intrauterine procedures or signs of infection.