Intrauterine synechiae and consequences of interventions
Morphologically, synechiae are dense whitish cords that occasionally contain blood vessels. As a rule, they are localized along the lateral walls of the uterus. Multiple transverse adhesions cause partial obliteration of the cavity, forming recesses that can be mistakenly perceived as the ostia of the uterine tubes during endoscopic examination.
The only effective treatment method is hysteroscopic adhesiolysis (resection). The surgery is performed under strict visual control, or under ultrasound or laparoscopic guidance in cases of significant obliteration. This is necessary to prevent perforation and protect the remaining intact endometrium.
A comprehensive approach is used to prevent recurrences:
- Mechanical barriers: insertion of a Foley catheter (for 1 day), an intrauterine contraceptive (for at least 1 month), or the use of anti-adhesion gels.
- Drug support: administration of high doses of estrogen-progestogens for 3–6 months to restore the mucous membrane.
The poorest prognosis for reproductive function recovery is observed in synechiae of tuberculous etiology. Pregnancy after treatment is associated with high risks: approximately 1/3 of cases account for spontaneous miscarriages, preterm birth, and placental abnormalities (placenta accreta, placenta previa).
Uterine septum
This is a congenital malformation accounting for 48–55% of all female genital anomalies (occurring in 2–3% of women in the general population). In this pathology, the single uterine cavity is divided into two hemicavities by a septum of varying length.
The primary clinical manifestation of the anomaly is pregnancy loss. The risk of spontaneous miscarriage in the first trimester reaches 28–60%. The negative impact on the fetus is caused by insufficient cavity volume, concomitant cervical incompetence, and abnormal embryo implantation on the avascular tissue of the septum.
For accurate diagnosis and differentiation from a bicornuate uterus, the combined use of hysteroscopy and laparoscopy is strictly mandatory, as the isolated endoscopic picture of these two conditions is identical. Three-dimensional ultrasound (3D US) also has high informativity (91–95%).
Treatment consists of hysteroscopic metroplasty—resection of the septum using endoscopic scissors, a hysteroresectoscope, or a laser. In cases of a complete septum, it is recommended to preserve its cervical portion to prevent secondary cervical incompetence. The efficacy of the operation is 70–85%, and the absence of a uterine scar allows for future planning of vaginal delivery.
Foreign bodies in the uterine cavity
Foreign bodies include intrauterine contraceptives (IUCs) and their fragments, fetal bone remnants, and surgical sutures. Their presence causes menstrual irregularities, secondary infertility, and chronic endometritis.
- Sutures (silk, lavsan): frequently detected against the background of persistent purulent discharge that does not respond to massive antibacterial therapy. The medical history of such patients typically includes cesarean section or conservative myomectomy. During hysteroscopy, they are visualized as whitish threads against a hyperemic mucous membrane.
- Bone fragments: are the consequence of late-term pregnancy termination (more than 13–14 weeks) complicated by repeated curettage. When retained in the uterus for more than 5 years, they acquire a coral-like shape and crumble upon an attempt to grasp them with forceps.
- IUC fragments: may cause uterine perforation and migrate into the omentum, intestine, or urinary bladder.
The removal of foreign bodies is performed exclusively under visual hysteroscopic control. Blind curettage is strictly contraindicated due to the high risk of trauma and perforation.
Endometrial cancer: differential diagnosis
Malignant endometrial lesions (uterine body cancer) manifest predominantly in postmenopause, with the average age of patients being 60–62 years. The lifetime risk of developing the disease is 2–3%. There are two main pathogenetic variants:
- Hormone-dependent (about 70% of cases): develops against the background of prolonged hyperestrogenism. Causes may include anovulation, obesity, diabetes mellitus, hormone-producing ovarian tumors, as well as tamoxifen intake or hormone replacement therapy. The cancer is preceded by background hyperplastic processes (the risk of malignant transformation in complex atypical hyperplasia reaches 29%). The tumor is typically a well-differentiated adenocarcinoma.
- Autonomous (less than 30% of cases): occurs against the background of marked endometrial atrophy without preceding metabolic and endocrine disorders. Depression of the T-cell immune system plays a leading role. This variant is characteristic of thin elderly women, is distinguished by low cell differentiation, early myometrial invasion, and an unfavorable prognosis.
Briefly: answers to topical questions
What is the classification of myoma nodes by location according to the FIGO system?
According to the FIGO system, the classification of myoma nodes is based on their location relative to the uterine layers (endometrium, myometrium, and serosa).
According to location and direction of growth, the following types are distinguished:
- Submucosal (submucous) — grow into the uterine cavity and deform it (subdivided into types 0, I, and II depending on the severity of the intramural component).
- Subserosal (subperitoneal) — grow toward the abdominal cavity (also divided into types 0, I, and II).
- Interstitial (intermuscular) — grow from the middle layer of the myometrium and are located within its thickness.
- Intraligamentary — as they grow, they split the leaves of the broad ligament of the uterus.
Which groups of drugs are used for conservative medical treatment of uterine fibroids?
The following groups of drugs are used for the conservative medical treatment of uterine fibroids:
- Progestogens — prescribed cyclically or continuously; contribute to reducing menstrual blood loss and normalizing hemoglobin levels.
- Antigestagens — gestrinone is used to induce medical menopause; mifepristone is at the stage of evaluation for the treatment of fibroids.
- Gonadotropin-releasing hormone agonists — goserelin, triptorelin, buserelin, and others; reduce the volume of myoma nodes by up to 55% and are most advisable in perimenopausal patients.
What types of endometrial hyperplasia exist according to the WHO classification, and what is the risk of their malignant transformation?
According to the modern binary WHO classification (2014, rev. 2020), two main forms of endometrial hyperplasia are distinguished.
- Endometrial hyperplasia without atypia — characterized by glandular proliferation without cytologic atypia. The risk of malignant transformation for simple hyperplasia is 1%, and for complex hyperplasia, it is about 3% (3 times higher).
- Endometrial hyperplasia with atypia (atypical endometrial hyperplasia) — differs by the predominance of the glandular component over the stroma and atypical changes in the glandular epithelium.
The earlier WHO classification (1994) also distinguished endometrial polyps, simple and complex endometrial hyperplasia, and hyperplasia with cellular atypia.
What complications, besides the formation of synechiae and suture fistulas, can occur after conservative myomectomy?
After conservative myomectomy, the following may occur:
- Formation of a uterine scar, the condition of which is important for the prognosis of subsequent pregnancy.
- Uterine rupture during subsequent pregnancy as a possible complication in the presence of a scar following myomectomy.
- In the presence of silk or lavsan sutures, chronic endometritis and pyometra are possible.
To memorize the main causes of hyperestrogenism in hormone-dependent endometrial cancer, use the "OSA" rule: Obesity, Diabetes mellitus (Сахарный диабет), Anovulation.
Class and exam questions
How to distinguish an intrauterine septum from a bicornuate uterus?
Isolated hysteroscopy does not allow distinguishing them, as the picture inside the cavity is identical. A combination of hysteroscopy and laparoscopy is required for a visual assessment of the external contours of the uterus.
In which phase of the cycle is it better to perform hysteroscopy to look for IUD fragments?
The study is strictly indicated in the early proliferative phase. During this period, the endometrium is still thin and does not obscure foreign bodies or their fragments.
What is the management when sutures are detected after conservative myomectomy?
Their targeted removal via hysteroscopy using special endoscopic instruments is indicated, as left-behind threads maintain chronic endometritis and pyometra.
Which pathogenetic variant of endometrial cancer has the worst prognosis?
An autonomous variant developing against the background of endometrial atrophy. It is characterized by low tumor differentiation, lack of sensitivity to hormone therapy, and early metastasis.
What else to study on this topic
- Technique of hysteroscopic adhesiolysis in Asherman syndrome
- Differential diagnosis of uterine malformations using MRI and spiral CT
- Pregnancy and childbirth management in patients after hysteroscopic metroplasty
- Morphological classification of endometrial hyperplastic processes and the risk of malignancy
- Clinical classification of uterine body cancer according to the FIGO system (stage 0 — in situ carcinoma and beyond)
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