A 34-year-old woman comes to the office seeking evaluation for infertility. She and her hu… — USMLE Step 2 CK

A 34-year-old woman comes to the office seeking evaluation for infertility. She and her husband have been having unprotected intercourse for the past $14$ months. Her only pregnancy resulted in a spontaneous abortion at $9$ weeks of gestation $18$ months ago, which was complicated by retained products of conception requiring a suction dilation and curettage. Prior to this event, her menstrual cycles occurred at regular 28-day intervals. Since the procedure, she has had complete cessation of menses. She reports no cyclical pelvic pain, headaches, visual changes, or galactorrhea. Her temperature is $36.8^\circ$ C ( $98.2^\circ$ F), blood pressure is $115/75$ mm Hg, pulse is $72$ /min, and BMI is $29$ kg/m $^2$ . She has mild facial acne that she has had since her teenage years. Pelvic examination reveals a normal-appearing cervix with no adnexal masses.

Laboratory testing shows:
$\beta$ -hCG: $< 5$ mIU/mL
Thyroid-stimulating hormone: $1.8$ $\mu$ U/mL
Prolactin: $14$ ng/mL
Follicle-stimulating hormone: $7$ mIU/mL
Luteinizing hormone: $6$ mIU/mL
Estradiol: $80$ pg/mL

Following a 10-day course of oral medroxyprogesterone acetate, the patient experiences no withdrawal bleeding. Which of the following is the most likely underlying cause of this patient's current condition?

Destruction of the basal layer of the endometriumCevap
B
Autoimmune-mediated depletion of ovarian follicles
C
Suppression of hypothalamic gonadotropin-releasing hormone pulsatility
D
Ischemic necrosis of the anterior pituitary gland
E
Hyperinsulinemia-driven excessive ovarian androgen production

Cevap

Destruction of the basal layer of the endometrium

The correct answer is the destruction of the basal layer of the endometrium. This patient presents with secondary amenorrhea and infertility directly following a dilation and curettage (D&C). Her normal FSH, LH, and estradiol levels indicate a functioning hypothalamic-pituitary-ovarian axis. Furthermore, the lack of withdrawal bleeding after a progestin challenge test demonstrates that her endometrium is unresponsive and not proliferating despite adequate endogenous estrogen. This clinical picture is highly specific for Asherman syndrome, a condition characterized by the formation of intrauterine synechiae (adhesions) due to iatrogenic destruction of the functional basal layer of the endometrium.

Adım Adım Çözüm

Evaluate the patient's clinical presentation and timeline.

The patient developed secondary amenorrhea and infertility immediately after a suction dilation and curettage for a spontaneous abortion.

Identifying the inciting event strongly suggests an anatomic or structural etiology rather than a new systemic disorder.

Interpret the endocrine laboratory evaluation.

The patient has normal TSH, prolactin, FSH, LH, and estradiol levels.

These normal values exclude systemic and central causes of amenorrhea such as thyroid disease, hyperprolactinemia, primary ovarian insufficiency (which would show high FSH), and functional hypothalamic amenorrhea (which would show low FSH/LH).

Analyze the results of the progestin challenge test.

There is no withdrawal bleeding following a 10-day course of oral medroxyprogesterone acetate.

A lack of withdrawal bleeding despite normal endogenous estradiol levels confirms that the endometrium is not proliferating, pointing to an anatomic outflow tract obstruction or unresponsiveness (Asherman syndrome).

Anahtar Kavram

Asherman syndrome is an anatomic cause of secondary amenorrhea characterized by intrauterine adhesions. It most commonly occurs after uterine instrumentation (such as dilation and curettage) and presents with normal ovarian and pituitary hormone levels, alongside an absence of withdrawal bleeding after a progestin challenge.

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