November 8, 2024

33-year-old patient post-nursing amenorrhea

By Med-Challenger · 2 minute read

A 33-year-old patient presents with a lack of menstruation since her son was born 18 months ago.

She has no known chronic medical conditions, takes no medications, and had an uncomplicated vaginal birth.

Twenty-four hours after delivery she experienced a postpartum hemorrhage secondary to the retained placenta and was taken to surgery for suction curettage of the uterus to remove the retained tissue. This procedure was uncomplicated and she did not require a blood transfusion. She nursed her child for 12 months postpartum.

After discontinuing nursing, she has not noticed a return of her menstrual cycle and is interested in conceiving another pregnancy soon.

Her thyroid-stimulating hormone is normal. Her body mass index is 26 kg/m2. You prescribe oral estrogen for 2 weeks followed by medroxyprogesterone 10 mg orally for 10 days and she does not have a withdrawal bleed.

Based on the information given, which of the following is the most likely cause for her lack of menses?

pituitary adenoma
polycystic ovarian syndrome
autoimmune ovarian destruction
Asherman syndrome
Sheehan syndrome

The correct answer is:

Asherman syndrome

Asherman syndrome is the most likely cause of amenorrhea in this patient. It is the only uterine cause of secondary amenorrhea and results from acquired scarring of the endometrial lining, usually secondary to postpartum hemorrhage or endometrial infection followed by instrumentation such as dilation and curettage.

Asherman syndrome should be suspected in a woman with secondary amenorrhea and a history of uterine infection or dilation and curettage for an obstetrical complication such as the one described in this case.

The diagnosis is suggested by the absence of a normal uterine stripe on ultrasound and the absence of withdrawal bleeding after the administration of estrogen and then progestin for several weeks. Hysteroscopic evaluation of the endometrium confirms the diagnosis. Sheehan syndrome also results in postpartum amenorrhea and can be associated with postpartum hemorrhage; however, women with this condition are often unable to lactate as a result of pituitary ischemia.

Reference:

Welt CK, Barbieri RL. Etiology, diagnosis, and treatment of secondary amenorrhea. In: Basow DS, ed. UpToDate. Waltham, MA: Wolters Kluwer Health; 2012. http://www.uptodate.com/contents/etiology-diagnosis-and-treatment-of-secondary-amenorrhea . Accessed August 7, 2012.

This question appears in Med-Challenger OBGYN Exam Review with CME

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