There are many patients who come to our center with irregular periods, such as long periods, heavy periods, incomplete menstrual bleeding, etc. There are many reasons for this, so today we will discuss the factor of cavity adhesions.
First of all, we need to clarify the concept of uterine adhesions.
As we all know, the endometrium is divided into a functional layer and a basal layer, the functional layer is the part that is shed every menstrual cycle and will recover on its own with the menstrual cycle. Once the basal layer is damaged, it is very difficult to repair to a certain extent. Uterine adhesions are partial or complete occlusions of the uterine cavity caused by damage to the basal layer of the endometrium, resulting in a series of complications such as abnormal menstruation, cyclic abdominal pain, infertility and recurrent miscarriage.
Causes and high-risk factors of uterine adhesions
Various causes of endometrial fibrosis and scarring, loss or thinning of the endometrium due to various degrees of damage to the endometrial basal layer, adhesions to the anterior and posterior walls of the uterus, and reduction in the volume of the uterine cavity can all lead to uterine adhesions. Three high-risk factors: mechanical manipulation of the uterine cavity, inflammatory uterine infections, and low estrogen status.
The American Society for Gynecologic Laparoscopy and the European Society for Gynecologic Endoscopy have introduced a new practice brief on uterine adhesions, with the following highlights.
1. Hysteroscopy – the gold standard for the diagnosis of uterine adhesions.
Compared to imaging, hysteroscopy provides a more accurate picture of the morphology of the uterine cavity, the degree of uterine adhesions and the quality of the endometrium, and allows for simultaneous treatment.
2. Regarding the classification of uterine adhesions.
The most common method of classification is to classify hysteroscopic adhesions as mild, moderate or severe according to the results of the hysteroscopic evaluation.
3. Regarding the management of uterine adhesions.
(1) Expectant treatment: This recommended treatment is older, with data showing that about 45.5% of patients are able to conceive within 7 years.
(2) Cervical dilation: reliable data for this treatment are available before the advent of hysteroscopy, and the use of this technique is now very limited.
(3) curettage: this was also the most common treatment before the advent of hysteroscopy, but it is no longer the best treatment because of the risk of further damage to the lining of the uterus.
(4) Hysteroscopy.
Advantages.
(1) It allows direct visualization and magnification of the uterine cavity for the treatment of adhesions;
② The examination requires simultaneous dilatation of the cervix, which allows simultaneous treatment of patients with mild cervical adhesions. However, it has some disadvantages. The more dense the adhesions are, the greater the risk of complications such as uterine perforation.
(5) Non-hysteroscopic techniques: open surgery and hysterotomy are rarely used nowadays because of their high trauma and complications.
4. Regarding post-operative hysteroscopy.
Approximately 30-60% of patients will experience postoperative recurrence, and guidelines for secondary prevention of hysteroscopic adhesions recommend the following.
(1) The use of IUDs, stents and catheters can reduce the recurrence rate of postoperative adhesions, but there are no data to support the improvement of infertility outcomes with these techniques;
(2) The use of solid barriers does not increase the risk of infection;
(3) IUDs containing progesterone or copper should not be used if a postoperative IUD is being considered;
(4) Semi-solid barriers such as hyaluronic acid reduce recurrence of uterine adhesions, but there are no data on the effect on infertility outcomes;
(5) The use of estrogen after hysteroscopic release of adhesions reduces the recurrence of adhesions;
(6) In addition, stem cell therapy, which is of great interest and more recent, may be effective in the treatment of post-abortion cavity adhesions, but evidence is limited.
5. Regarding postoperative evaluation.
The recurrence rate is about 1/3 for mild to moderate hysterosal adhesions and up to 2/3 for severe patients; therefore, regardless of whether the patient has undergone surgical treatment, follow-up of the uterine cavity should be performed, usually with hysteroscopy or hysterosalpingography after two to three postoperative menstrual cycles.