Amenorrhea (Intrauterine Adhesions) Case File
Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD
CASE 49
A 33-year-old woman complains of 7 months of amenorrhea following a spontaneous abortion. She had a dilation and curettage (D&C) at that time. Her past medical and surgical histories are unremarkable. She experienced menarche at age 11 years and notes that her menses have been every 28 to 31 days until recently. Her general physical examination is unremarkable. The thyroid is normal to palpation, and breasts are without discharge. The abdomen is nontender. The pelvic examination shows a normal uterus, closed and normal appearing cervix, and no adnexal masses. A pregnancy test is negative.
» What is the most likely diagnosis?
» What is the test to confirm the diagnosis?
» What would be the patient’s response if a progestin challenge is administered?
ANSWER TO CASE 49:
Amenorrhea (Intrauterine Adhesions)
Summary: A 33-year-old woman complains of 7 months of amenorrhea after she had a D&C for a spontaneous abortion. Her menstrual history was normal previously. The thyroid, pelvic, and breast examinations are normal. The pregnancy test is negative.
- Most likely diagnosis: Intrauterine adhesions (IUA; Asherman syndrome).
- Test to confirm diagnosis: Hysterosalpingogram or saline infusion sonohysterogram (or hysteroscopy).
- Response to progestin challenge: No bleeding due to unresponsive endometrium.
ANALYSIS
Objectives
- Know the definition of secondary amenorrhea.
- Understand how uterine curettage can cause endometrial adhesions and amenorrhea.
- Know how to diagnose intrauterine adhesive disease (Asherman syndrome).
Considerations
This 33-year-old woman has had 7 months of amenorrhea since experiencing a miscarriage. She had undergone a uterine dilation and curettage at that time. Her menstrual history was unremarkable previously; hence, she meets the definition of secondary amenorrhea (6 months of no menses in a woman with previously normal menses). Pregnancy is the most common cause of secondary amenorrhea and thus, should be the first condition to be ruled out. The stepwise algorithm to assess for the etiology for amenorrhea is noted in Figure 49– 1. Secondary amenorrhea may be caused by hypothalamic etiologies (such as hypothyroidism or hyperprolactinemia), pituitary conditions (such as Sheehan syndrome), or ovarian causes (such as premature ovarian failure). The patient does not have symptoms of hypothyroidism or galactorrhea, or hot flushes. Additionally, her history indicates that prior to an acute event, her miscarriage, she had regular menses. With no indication of a postpartum hemorrhage, the most probable source of her amenorrhea is an issue with the end organ, her uterus. Hence, the most likely diagnosis is intrauterine adhesions, arising from the curettage of the uterus. With this condition, the hypothalamus, pituitary, and ovary are working normally, but the endometrial tissue is not responsive to the hormonal changes. To confirm that the uterine cavity is obliterated with adhesions, a hysterosalpingogram, a radiologic study where radiopaque dye is injected into the uterine cavity via a transcervical catheter, or saline infusion ultrasound study can be used.
Figure 49–1. Algorithm to assess secondary amenorrhea.
APPROACH TO:
Suspected Intrauterine Adhesions
DEFINITIONS
PRIMARY AMENORRHEA: Not achieving menarche by age 16 while having normal breast development.
SECONDARY AMENORRHEA: Absence of menses in a previously menstruating women for a period of 6 months.
INTRAUTERINE ADHESIONS: Condition when scar tissue or synechiae form to obliterate the endometrial cavity, usually occurring because of uterine curettage following a pregnancy.
HYSTEROSALPINGOGRAM: A radiologic study in which radiopaque dye is injected into the endometrial cavity via a transcervical catheter, used to evaluate the endometrial cavity and/ or the patency of the fallopian tubes.
HYSTEROSCOPY: Procedure of direct visualization of the endometrial cavity with an endoscope, a light source, and a distension media.
SALINE INFUSION SONOHYSTEROGRAPHY (SIS): A vaginal ultrasound procedure in which fluid is infused transcervically into the uterine cavity to provide enhanced visualization of the endometrial cavity.
UTERINE SOUNDING: Assessing the depth and direction of the cervical and uterine cavity with a thin blunt probe.
CLINICAL APPROACH
Intrauterine Adhesions (Asherman Syndrome)
Intrauterine scarring resulting in an unresponsive endometrium accounts for approximately 7% of cases of amenorrhea. It is most commonly due to injury to the pregnant or recently pregnant uterus secondary to curettage leading to damage of the endometrial basalis layer. However, any mechanical, infectious, or radiation factor can produce endometrial sclerosis and adhesion formation, including common uterine surgeries like cesarean sections and myomectomies. The adhesions are usually strands of avascular fibrous tissue, but they may also consist of inactive endometrium or myometrium. Myometrial adhesions are usually dense and vascular carrying a poor prognosis. Women with atrophic and sclerotic endometrium without adhesions carry the worst prognosis. This is usually found after radiation or tuberculous endometritis and is not amenable to any therapy. Postpartum curettage performed usually for concerns for retained products of conception, combined with hypoestrogenic states such as breast-feeding or hypogonadotropic hypogonadism, is associated with extensive intrauterine scar formation. Uterine curettage performed after a missed abortion is associated with a higher incidence of intrauterine synechiae than curettage performed after an incomplete abortion or a molar pregnancy. Adhesions may also form after a diagnostic D&C. In general, the routine use of uterine curettage at the time of a diagnostic laparoscopy is unwarranted and may damage the endometrium.
Intrauterine adhesions should be suspected if a woman presents with secondary amenorrhea, a negative pregnancy test, and does not have progestin-induced withdrawal bleeding (see Table 49– 1 for etiologies). There is no consistent correlation between the menstrual bleeding patterns and the extent of intrauterine adhesions. The diagnosis of IUA should be suspected in every patient with infertility, recurrent abortions, uterine trauma, and menstrual abnormalities. The most common methods of diagnosing IUA are by hysterosalpingogram or SIS. Classic hysterosalpingogram findings include irregular, angulated filling defects within the uterine cavity. In cases of severe intrauterine adhesions, the cavity cannot be sounded, making the procedure very difficult to perform. Vaginal ultrasound without saline lacks specificity. Saline infusion sonohysterography is an excellent complement to the vaginal ultrasound and can allow for the evaluation of the uterine cavity. Magnetic resonance imaging (MRI) is expensive and does not offer a greater advantage over the other diagnostic modalities. Hysteroscopy allows for direct visualization of the uterine cavity and is considered the “gold standard” for the establishment of the diagnosis and extent of the IUA.
Operative hysteroscopy is the ideal treatment for IUA that allows direct transection of adhesions. The postoperative management may include the insertion of an IUD or preferentially a pediatric Foley catheter for 7 days postoperatively to prevent the recently lysed adhesions from reforming. In addition, the administration of conjugated estrogens and progesterone (medroxyprogesterone acetate) should be considered. Repetitive treatments may be necessary to regain reproductive potential. The uterine cavity should be re-evaluated prior to attempting conception. Although 70% to 80% of patients with IUA have been able to achieve pregnancies, these pregnancies are at an increased risk of being complicated by premature labor, placenta accreta, placenta previa, and/ or postpartum hemorrhage.
|
CASE CORRELATION
|
COMPREHENSION QUESTIONS
49.1 A 34-year-old woman states that she has had no menses since she had a uterine curettage and cone biopsy of the cervix 1 year previously. Since those surgeries, she complains of severe, crampy lower abdominal pain “similar to labor pain” for 5 days of each month. Her basal body temperature chart is biphasic, rising 1°F for 2 weeks of every month. Which of the following is the most likely etiology of secondary amenorrhea?
A. Hypothalamic etiologyB. Pituitary etiologyC. Uterine etiologyD. Cervical condition
49.2 A 29-year-old G2P0 woman underwent an evaluation for amenorrhea of 10 months duration. Her menses had been regular previously. A pregnancy test, thyroid stimulating hormone (TSH), prolactin level, follicle stimulating hormone (FSH), and luteinizing hormone (LH) levels were normal. The patient had sequential estrogen and progestin therapy without vaginal bleeding. Her presumptive diagnosis was intrauterine adhesions, which was confirmed with imaging. Which of the following statements is most accurate?
A. Her condition usually occurs after uterine curettage for a pregnancyrelated process.B. She would best be diagnosed by laparoscopy.C. The patient likely has cramping pain every month.D. Her treatment includes endometrial ablation.
49.3 A 32-year-old G1P1 woman presents with an 8-month history of amenorrhea. A pregnancy test is negative. TSH and prolactin levels are normal. The FSH level is elevated at 40 IU/ L. Which of the following is the most likely complication for this patient?
A. She is at significant risk for endometrial cancer.B. She is at increased risk for ovarian cancer.C. She is at increased risk for osteoporosis.D. She is at increased risk for multiple gestations.
49.4 If the patient in question 49.3 were to have a diagnostic work-up, which of the following is most likely to be noted?
A. Obliterated uterine cavity on saline infusion sono-HSGB. No bleeding with a progestin challenge testC. Normal level of estradiolD. Abnormal MRI of the brain
49.5 A 41-year-old woman is suspected of having intrauterine adhesions because she has had irregular menses since a spontaneous abortion 18 months previously. Which of the following historical or laboratory pieces of information would support this diagnosis?
A. Presence of hot flushesB. FSH level too low to be measurableC. Normal estradiol levels for a reproductive-aged womanD. Monophasic basal body temperature chart
ANSWERS
49.1 D. This patient has two potential causes for amenorrhea: IUA caused by the uterine curettage and cervical stenosis due to the cervical conization. The biphasic basal body temperature chart suggests normal functioning of the hypothalamus– pituitary– ovarian axis. The crampy abdominal pain most likely is due to retrograde menstruation; thus, this is most likely due to a cervical process, cervical stenosis. If untreated, this patient would likely develop severe endometriosis.
49.2 A. Uterine curettage for a pregnancy-related process predisposes to IUA. This is best diagnosed with hysteroscopy (direct visualization of endometrial cavity) and not laparoscopy (visualized intraperitoneal cavity). Cervical stenosis, and not IUA, is associated with cramping pain every month. Ideal treatment for Asherman is operative hysteroscopy. The patient has had a work-up for secondary amenorrhea, which is fairly standard consisting of pregnancy test, prolactin, and TSH levels, which would alter GnRH pulsations, and FSH and LH assessing ovarian failure. Sequential estrogen and progestin without bleeding indicates a uterine/ cervical etiology.
49.3 C. This patient has secondary amenorrhea. Her pregnancy test is negative. The TSH and prolactin levels are normal. Her serum FSH level is elevated, indicating that she has premature ovarian failure. Due to the low estrogen levels, she is at risk for osteoporosis. She is not at risk for endometrial cancer. Patients with polycystic ovarian syndrome (PCOS) would be at risk for endometrial cancer due to unopposed estrogen.
49.4 B. This patient likely has premature ovarian failure since the gonadotropin levels are markedly elevated. The estradiol levels are most likely low, and the patient would not respond to the progestin challenge test since the endometrium is too thin to yield any endometrial shedding. The uterine cavity should be normal in shape. The MRI of the brain is normal.
49.5 C. With IUA, the hormonal status of the woman should be normal. This would exclude the possibility of ovarian failure (hot flushes), low FSH levels, and a monophasic basal body temperature chart since these are all indications of an abnormal hormonal status.
CLINICAL PEARLS
|
» After pregnancy is ruled out, the most common cause of secondary amenorrhea after uterine curettage is intrauterine adhesions. » Secondary amenorrhea can be caused by abnormalities in one of four compartments: hypothalamus, pituitary, ovary, and uterus (outflow tract). » Intrauterine adhesions are diagnosed by hysterosalpingogram or saline infusion sonohysterography and confirmed by hysteroscopy. » Hysteroscopic resection is the best treatment of intrauterine adhesions. » Uterine curettage, especially associated with pregnancy, is a risk factor for intrauterine adhesions. » The evaluation of secondary amenorrhea includes a pregnancy test, prolactin level, TSH level, and assessment of gonadotropin levels. |
REFERENCES
Alexander CJ, Mathur R, Laufer LR, Aziz R. Amenorrhea, oligomenorrhea, and hyperandrogenic disorders. In: H acker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 6th ed. Philadelphia, PA: Saunders; 2015:355-367.
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham FG. Amenorrhea. Williams Gynecology. 2nd ed. New York, NY: McGraw H ill Medical; 2012:440-459.
Lentz GM. Primary and secondary amenorrhea and precocious puberty. In: Katz VL, Lentz GM, Lobo RA, Gersenson DM, eds. Comprehensive Gynecology. 6th ed. St. Louis, MO: Mosby-Year Book; 2012:933-960.
Speroff L, Fritz MA. Amenorrhea. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:401-463.
Tur-Kaspa I, Gal M, Hartman M, Hartman J, Hartman A. A prospective evaluation of uterine abnormalities by saline infusion sonohysterography in 1009 women with infertility or abnormal uterine bleeding. Fertil Steril. 2009;86(6):1731-1735.
0 comments:
Post a Comment
Note: Only a member of this blog may post a comment.