Question of the Week # 392

392)  A 28 year old woman presents with a history of amenorrhea of about 6 month duration. She does not have any breast discharge, visual deficits or headaches. Her home pregnancy test was negative a week ago. Her past medical history is significant for three missed abortions for which she underwent dilatation and curettage. On examination, her vitals are stable. Body mass index is about 22 . Breast examination is normal with out any discharge.  Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  A trial of medroxyprogesterone and a later trial of estrogen-progesterone combination fails to induce bleeding. Which of the following is the most appropriate next step?

A) Anti-phospholipid Antibodies

B) Hysteroscopy

C) Dehydro-epiandrosterone level

D) Pituitary MRI

E) Ultrasound of Ovaries

11 Responses

  1. C) Hysteroscopy
    This is Asherman’s Syndrome-intrauterine adhesion due to adverse effect of Dilatation and Curettage. Confirmed with Hysteroscopy.

  2. b-hysteroscopy to r/o adhesions

  3. Both a trial of progesterone and estrogen-progesterone combination have failed to induce bleeding so her ovaries are not functioning –>do US to see if there are follicles present in the ovaries. If there are no follicles then its premature ovarian failure…if there are follicles then its resistant ovary syndrome.
    But given her h/o missed abortions she probably is positive for Anti-phospholipid Antibodies.That means she is prone to autoimmune disorders which probably also is the cause for her premature ovarian failure.but we first need to see if there are follicles in the ovary.

    E) Ultrasound of Ovaries

  4. In Secondary amenorrhea,
    Start with Pregnancy test–>If negative, do TSH, Prolactin level–>Then Progesterone Challenge test—>If positive, diagnosis of anovulation. If negative, do Estrogen-Progesterone challenge test.

    If EPCT is positive, diagnosis of inadequate estrogen, next step is to do FSH level. FSH is high, then ovarian failure. If FSH is low, order Brain CT/MRI to rule out tumor.

    If EPCT is negative (like in this case), outflow tract obstruction or endometrial scarring (Asherman Syndrome)—>do hysteroscopy or hysterosalpingogram.

    Correct me if I go the wrong track.

  5. b, hx of surgical prosedure and the anterior test are neg

  6. Due to past history of 3 D&C and negative estrogen progesterone challenge test in a previously menstruating it is Sherman syndrome and answer is B

  7. Due to past history of 3 D&C and negative estrogen progesterone challenge test in a previously menstruating it isAsherman syndrome and Answer is B

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