A 32-year-old woman comes to the office for evaluation of absent menses. The patient had a vaginal delivery 4 months ago, and she has not had a menstrual period since delivery. Her postpartum course was complicated by a postpartum hemorrhage, requiring blood transfusion and emergency suction and sharp curettage. At her postpartum visit 2 months ago, the patient was started on combination oral contraceptives and has had no vaginal bleeding or spotting during her week of placebo pills. Prior to this pregnancy, she had regular, monthly menstrual cycles with 3-4 days of moderate bleeding. The patient has had increased fatigue since returning to work and is bottle-feeding. She has no headaches, galactorrhea, or hot flushes. Vital signs are normal. BMI is 31 kg/m². Pelvic examination shows clear vaginal discharge throughout the vault and a well-rugated vagina. The uterus is small and anteverted, and there are bilateral small, nontender ovaries. Urine pregnancy test is negative. FSH and TSH levels are normal. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9a2_e12a_bc81_dd2c5d580936_MD0003_00 This patient has Asherman syndrome, the formation of intrauterine adhesions that can follow intrauterine surgery, such as an emergency suction and sharp curettage. Asherman syndrome occurs commonly after suction and sharp curettage for delivery complications, such as postpartum hemorrhage and endometritis, because the postpartum uterus is soft, enlarged, and more prone to aggressive curettage. During this procedure, the basalis layer of the endometrium can inadvertently be injured, creating a denuded, adherent intrauterine surface prone to synechiae and endometrial cavity obliteration. Because of complete or partial obliteration of the endometrium, patients typically develop very light menses or secondary amenorrhea that does not respond to a progesterone challenge, as evidenced by no withdrawal bleeding during the placebo week of oral contraceptives. Asherman syndrome is a structural cause of amenorrhea; therefore, patients have normal FSH and TSH levels. Diagnosis and treatment are via hysteroscopy, which can lyse adhesions. (Choice B) Gestational trophoblastic disease (eg, choriocarcinoma) can cause abnormal uterine bleeding after pregnancy. The persistent trophoblastic tissue secretes hCG; this patient has a negative pregnancy test, making this diagnosis unlikely. (Choice C) Polycystic ovary syndrome causes abnormal uterine bleeding, particularly in obese patients (BMI ≥30 kg/m²). However, patients have a thickened endometrium due to chronic anovulation and continued endometrial proliferation; therefore, they would have bleeding during the placebo week of oral contraceptives. ² (Choice D) Postpartum thyroiditis is autoimmune transient thyroid disorder that can occur within a year after delivery. Symptoms can include abnormal uterine bleeding and fatigue; however, patients have abnormal TSH levels, making this diagnosis unlikely. (Choice E) Because of low estrogen levels, primary ovarian insufficiency can cause secondary amenorrhea and no withdrawal bleeding during the placebo week of oral contraceptives. However, these patients have an elevated FSH level, making this diagnosis unlikely. (Choice F) Sheehan syndrome can occur as a complication of postpartum hemorrhage, particularly if associated with massive hemorrhage requiring blood transfusion and emergency suction curettage. Patients can have amenorrhea, fatigue, and inability to breastfeed; however, they have low FSH and TSH levels due to panhypopituitarism, which is not seen in this patient. In addition, fatigue is a nonspecific symptom common in patients with infants at home. Educational objective: Asherman syndrome, the formation of intrauterine adhesions, often occurs following intrauterine surgery (eg, suction curettage). Patients with Asherman syndrome typically have amenorrhea that does not respond to a progesterone challenge due to obliteration of the endometrium. References: A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/28582327) Hysteroscopic management of Asherman's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/29024798) Asherman's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21437822)

A 32-Year-Old Woman Comes to the Office for Evaluation of Absent