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Zorluk: KolayReproductive Endocrinology and Infertility

A 34-year-old woman comes to the office for evaluation of secondary amenorrhea. Her last menstrual period was 14 months ago. At that time, she underwent a dilation and curettage for an incomplete abortion, which was complicated by postpartum endometritis requiring intravenous antibiotics. Prior to this pregnancy, her menstrual cycles were regular every 28 days. She reports no hot flashes, galactorrhea, weight changes, or visual disturbances. Her body mass index is 23 kg/m². Physical examination reveals normal secondary sexual characteristics and no evidence of hirsutism or acne. A urine pregnancy test is negative. Serum laboratory testing shows normal levels of follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone. A 10-day course of oral medroxyprogesterone acetate is administered, but no withdrawal bleeding occurs. Subsequently, she is given a 21-day course of oral estrogen followed by 7 days of progestin, which also fails to induce withdrawal bleeding. Which of the following is the most likely diagnosis?

  1. Intrauterine synechiaeCevap
  2. B
    Polycystic ovary syndrome
  3. C
    Primary ovarian insufficiency
  4. D
    Functional hypothalamic amenorrhea
  5. E
    Secondary hypothyroidism

Cevap

Intrauterine synechiae
The correct answer is intrauterine synechiae (Asherman syndrome). This patient has secondary amenorrhea with a classic history of uterine instrumentation (dilation and curettage) complicated by endometritis. In the standard evaluation of amenorrhea, a failure to experience withdrawal bleeding after both a progestin challenge and a subsequent estrogen-progestin challenge indicates an anatomic defect of the outflow tract, such as endometrial destruction or scarring. Her normal hormone levels further rule out central and ovarian etiologies.

Adım Adım Çözüm

1
Analyze the patient's presenting symptoms and medical history.
The patient has secondary amenorrhea following a dilation and curettage complicated by an intrauterine infection (endometritis).
Identifying the antecedent event is critical for suspecting an anatomic cause of secondary amenorrhea.
2
Interpret the laboratory findings.
Follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone are all within normal limits.
Normal pituitary, thyroid, and ovarian hormones rule out primary ovarian insufficiency, hypothalamic amenorrhea, and hyperprolactinemia.
3
Evaluate the response to hormonal challenge tests.
The patient fails to bleed after a progestin challenge and after subsequent sequential estrogen-progestin therapy.
Failure to bleed despite adequate exogenous estrogen and progestin confirms an unresponsive endometrium or obstructed outflow tract, diagnosing intrauterine synechiae.

Anahtar Kavram

In the workup of secondary amenorrhea, a failure to experience withdrawal bleeding after sequential exogenous estrogen and progestin administration points to an anatomic outflow tract defect, most commonly Asherman syndrome (intrauterine synechiae) when there is a history of uterine instrumentation.
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Reproductive Endocrinology and Infertility

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