Ultrasound plays a complementary and vital role in the diagnosis and management of intrauterine adhesions (IUA), a kind of lesion often associated with Asherman's syndrome. Since IUA was first described in the late 1800s, according to Gynecological Surgery, the steps to diagnose and treat it have evolved thanks to advancements in medical technology. One relatively new step in the process is hysteroscopic adhesiolysis.
Gone are the painful hysterosalpingograms (HSG) performed under fluoroscopy. Gone are the blind dilation and curettage to probe for cervical stenosis and obstruction of the cavity. Today, in-office ultrasound and procedure suites or out-patient ambulatory surgery centers have largely replaced hospital radiology and ORs in the diagnosis and management of a patient with IUA.
Signs of Possible Uterine Adhesions
The symptoms of this disorder have not changed since it was first described over a century ago. Most commonly, IUA is associated with infertility and a range of menstrual disturbances, including hypomenorrhea, amenorrhea and dysmenorrhea. While IUA and Asherman's syndrome are sometimes used interchangeably, Gynecological Surgery notes that diagnosing the syndrome requires a combination of pain, subfertility and menstrual issues caused by IUAs.
When a patient presents with a history of secondary amenorrhea, especially in the setting of a recent intrauterine procedure, the endometrium should be evaluated. For example, a patient may present with IUA after dilation and curettage for a miscarriage or retained products of conception. Thorough ultrasound evaluation is the most productive and economical starting point for evaluation.
A thin endometrium on 2D transvaginal ultrasound may denote agglutination of the uterine walls with complete obliteration of the uterine cavity. An irregular endometrium with hyperechoic areas may represent focal areas of scar tissue. Adding 3D ultrasound will provide superior visualization of the endometrial-myometrial junction and a sweeping view of the uterine cavity, especially in the coronal plane. Saline or gel infusion sonogram (SIS or GIS) may further demonstrate filling defects or adhesions that can appear filmy or dense, and Doppler can demonstrate vascular compromise of the endometrium secondary to the presence of scar tissue.
Diagnosing and Treating IUA With Hysteroscopic Adhesiolysis
When the ultrasound raises the suspicion of IUA, the gold standard for diagnosis remains hysteroscopic adhesiolysis, which allows diagnosis and surgical intervention simultaneously. Under direct visualization or guided by transabdominal ultrasound, precise hysteroscopic resection of the fibrous bands in the uterine cavity is followed by mechanical separation of the walls, most commonly with a balloon catheter and hormonal treatment.
Classifying Uterine Adhesions
Classification systems are helpful in describing the extent of disease and in counseling patients about prognosis. According to the Australasian Journal of Ultrasound in Medicine, the two most commonly used classification systems come from the American Society for Reproductive Medicine (ASRM) and the European Society of Hysteroscopy (ESH). They were designed and based on hysteroscopic and HSG assessments, although HSG has largely been replaced by SIS and 3D transvaginal ultrasound.
Each system describes the severity of the adhesions by grade or stage, and includes other key features such as the extent of their location and appearance and the patient's associated menstrual irregularity. Some continue to advocate for laparoscopy at the time of hysteroscopy for selected patients, as endometriosis and IUA are commonly associated in patients with a history of infertility and dysmenorrhea.
Patients with intrauterine adhesions no longer need to undergo painful probing to find the source of their pain. Today, IUA can be diagnosed and treated safely in the comfort of the outpatient setting or office thanks to advancements in medical technology such as ultrasound and hysteroscopy.
