Intrauterine adhesions develop as a result of intrauterine trauma. The degree of adhesion formation and the impact of the adhesions on the contour of uterine cavity vary greatly. With minimal disease, thin bands of tissue stretch between surfaces of the uterine cavity, whereas severe disease is characterized by complete obliteration of the cavity, with the anterior wall of the uterus densely adherent to the posterior wall.
Approximately 90 percent of cases of severe intrauterine adhesive disease are related to curettage for pregnancy complications, such as missed or incomplete abortion, postpartum hemorrhage, or retained placental remnants [1,2]. Repeated curettage for pregnancy loss increases the risk of developing adhesions from 8 percent after the first curettage to over 30 percent with the third curettage . The basalis layer of the endometrium appears to most susceptible to damage in the first four postpartum or postabortal weeks; however, adhesions can develop in the nongravid uterus as a result of endometrial injury from procedures such as myomectomy or nonpuerperal curettage .
The role of postpartum or postabortal infection in adhesion formation is controversial, and data are limited. A study that evaluated 28 women with significant postcesarean delivery endometritis by hysteroscopy reported the frequency of adhesions in these women was similar to that in controls without postcesarean infection . Another study reported a nonsignificant increase in adhesion formation when dilation and curettage was performed in the presence of concurrent infection . Trauma is the major cause of intrauterine adhesions, although infection may play a minor contributing role.
In the developing world, genital tuberculosis is a cause of intrauterine adhesions, which are often severe with complete obliteration of the uterine cavity . These patients typically present with amenorrhea and cyclic pelvic pain. The adhesions are believed to form secondary to chronic inflammation of the endometrium. (See "Postpartum endometritis".)
Intrauterine adhesions can be asymptomatic and of no clinical significance. Symptoms associated with clinically significant intrauterine adhesions include: