A System Review of Pathophysiology, Diagnosis, and Clinical Management of Intrauterine Adhesions

Importance: Intrauterine adhesions are a major cause of menstrual abnormalities, infertility, and adverse obstetric outcomes, most commonly resulting from iatrogenic endometrial injury after uterine curettage. Despite advances in hysteroscopic treatment, prevention, recurrence, and endometrial regeneration remain unresolved clinical challenges. Objective: To elucidate the pathogenesis of intrauterine adhesions, particularly curettage-induced injury, and to summarize current diagnostic methods, classification systems, and evidence-based treatments, including emerging regenerative strategies to reduce adhesion formation and recurrence. Evidence Acquisition: PubMed, Web of Science, and Embase were searched for studies on IUA pathogenesis, diagnosis, and management, with emphasis on curettage methods, hysteroscopic treatment, adjuvant therapies, and emerging biological interventions. Results: Evidence indicates that IUA develops through basal endometrial injury followed by dysregulated inflammation, impaired angiogenesis, and excessive fibrotic repair. Sharp curettage, particularly when repeated or unguided, confers a higher adhesion risk than vacuum aspiration. Hysteroscopy is the diagnostic gold standard and guides severity-based classification. Hysteroscopic adhesiolysis remains the primary treatment, with technique selection based on adhesion extent. Adjunctive therapies, including estrogen, antifibrotic agents, physical barriers, and emerging biologics, may enhance endometrial regeneration and reduce recurrence, though efficacy varies across disease severity. Conclusions and Relevance: Clinicians should prioritize strategies that minimize endometrial trauma during uterine evacuation, including the preferential use of vacuum aspiration and image-guided techniques. Optimized hysteroscopic management combined with appropriate adjuvant therapies is essential to reduce recurrence and improve reproductive outcomes in women with IUAs.