Published 24 June 2009, doi:10.1136/bmj.b2282
Cite this as: BMJ 2009;338:b2282

Endgames

Case report

A case of secondary amenorrhoea

¹ Derby City General Hospital, Derby DE22 3NE

Case history

A 28 year old woman was referred by her general practitioner with secondary amenorrhoea. She had had an uneventful pregnancy with the normal delivery of a baby girl 18 months previously. She was readmitted to hospital shortly after delivery because of postpartum haemorrhage and underwent evacuation of retained products of conception. The patient was taking the progesterone only contraceptive pill after delivery, but treatment was stopped after 10 months because of an absence of any menstruation. Since discontinuing oral contraception, she had not menstruated for a further 9 months. Otherwise, she had no relevant medical history and no family or drug history. Her menstrual cycle was normal before pregnancy and her body mass index was 22.5. Examination showed no evidence of galactorrhoea or abdominal mass. The vagina and cervix were normal on speculum examination. On palpation, the uterus was of normal size and anteverted, with no adnexal masses. These findings were confirmed by transvaginal ultrasound, which also showed that the texture of the myometrium was slightly heterogeneous in places with irregular endometrial thickness (up to 6 mm in isolated pockets). Biochemical investigations showed normal thyroid function and normal serum levels of prolactin. Serial hormone tests over 3 weeks—including serum concentration of luteinising hormone, follicle stimulating hormone, oestradiol, and progesterone—indicated normal cyclical ovarian activity.

Questions

1 What is the likely clinical diagnosis given the patient’s history and the findings on investigation?

2 What other investigations would you carry out in addition to those mentioned above?

3 How would you treat this patient?

Answers

Short answers

1 This patient has Asherman’s syndrome, a condition characterised by scarring of the uterine cavity.

2 Hysteroscopy is recommended in a patient with these symptoms.

3 Hysteroscopically directed division of adhesions is the optimum treatment.

Long answers
1 Asherman’s syndrome
Asherman’s syndrome describes the occurrence of intrauterine adhesions. Any insult to the endometrium can predispose to the formation of intrauterine adhesions at opposing surfaces of the uterus, which can partially or completely obliterate the uterus.¹ Although Asherman’s syndrome is uncommon, the incidence of this disorder has been rising steadily,² possibly as a result of the increased incidence of elective abortion.^{3 4} There are several classification systems that can be used to grade the severity of intrauterine adhesions and to predict prognosis (table 1).

View this table: [in this window] [in a new window]   Table 1 Classification of intrauterine adhesions

 
The main aetiological risk factor for Asherman’s syndrome is surgical trauma to a recently pregnant uterus. The endometrium is highly susceptible to adhesions, particularly between week 2 and week 4 postpartum.⁵ The most common mechanism is injury to the pars basalis of the endometrium. Asherman’s syndrome mostly affects women who have had dilatation and curettage, especially those who have undergone this procedure postpartum, for the removal of retained products of conception or to abort a pregnancy.^{3 6 7} Other causes of Asherman’s syndrome include surgical trauma to the non-gravid uterus (for example, via dilatation and curettage or endometrial ablation),^{3 8 9} and uterine infection, including genital tuberculosis and schistosomiasis.^{10 11}

Clinical presentations include secondary amenorrhoea or oligomenorrhoea, recurrent miscarriage, infertility, and, possibly, dysmenorrhoea.^{12 13} It is important to suspect Asherman’s syndrome in women with any of these signs, especially in those who have a history of dilatation and curettage, in order to avoid delays in diagnosis and treatment.

2 Investigations
Pregnancy is the most frequent cause of amenorrhoea in women of childbearing age (whether on oral contraception or not); therefore, pregnancy should be excluded before any further investigations are undertaken.

Asherman’s syndrome is diagnosed by hysteroscopy and hysterosalpingography (table 2). Hysterosalpingography uses contrast media to allow indirect visualisation of endometrial lesions such as filling defects or uterine wall irregularities. In contrast, hysteroscopy enables direct visualisation of the uterine cavity with a hysteroscope and is considered the diagnostic method of choice. This technique confirms the diagnosis and determines the severity of Asherman’s syndrome,¹³ and is associated with a higher accuracy than hysterosalpingography.^{14 15 16}

View this table: [in this window] [in a new window]   Table 2 Hysterosalpingography v hysteroscopy

 
In this patient, hysteroscopy showed a narrowed uterine cavity with a very fibrotic scarred endometrium and uterine adhesions (figs 1 and 2). Hysteroscopy also allows lesion biopsy (to obtain a histology sample with which the diagnosis can be confirmed) and can be used to guide surgery, if indicated. Hysterosalpingography and hysteroscopy are often regarded as complementary in diagnosing intrauterine adhesions; however, hysterosalpingography is used to screen for intrauterine abnormalities before hysteroscopy is used to confirm the diagnosis or to identify any further uterine abnormalities not observed on hysterosalpingography.^{14 16} In patients who present with infertility, hysterosalpingography is the gold standard for assessing potential tubal blockage; hysteroscopy is unsuitable for this purpose.

View larger version (708K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Figure 1 Narrowed uterine cavity with very fibrotic scarred endometrium in a patient with Asherman’s syndrome

 

View larger version (760K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Figure 2 Uterine adhesions in a patient with Asherman’s syndrome

 
3 Treatment
The treatment of Asherman’s syndrome consists of two approaches: (1) management of adhesions; and (2) prevention of further adhesions. The overall aims are to restore the size and shape of the uterine cavity and to restore normal endometrial function. The lysis of intrauterine adhesions (adhesiolysis) under hysteroscopic guidance is considered the gold standard for treatment,¹⁷ as direct visualisation of endometrial defects renders adhesiolysis safer and more effective. Techniques for dividing adhesions include forceps or scissors,^{18 19} electrosurgery, and laser energy.^{20 21 22} Hysteroscopy is effective for mild to moderate Asherman’s syndrome;^{17 19 23} however, severe intrauterine adhesions may need to be treated with hysteroscopic adhesiolysis,^{21 24} which sometimes may not be successful at first attempt.¹⁸ If the uterine cavity is obliterated completely, a combination of hysteroscopy and laparoscopy is required.^{21 25} The main risks of hysteroscopy include uterine perforation and haemorrhage from uterine vascular damage.²⁵ It is therefore crucial to maintain the orientation of the uterus and of landmarks throughout the procedure by keeping the hysteroscope upright and by visualising the landmarks during the procedure. The use of concurrent ultrasonography to facilitate the passage of the hysteroscope through the endocervical canal and the internal orifice of the uterus into the uterine cavity might be necessary in severe cases. Evidence shows that abdominal ultrasound and fluoroscopy using contrast medium can help minimise the risk of injury during this procedure.^{20 26}

The severity of Asherman’s syndrome determines the success of treatment. Success rates are measured by the restoration of normal menstruation, subsequent live term deliveries, and reduced miscarriage rates. A normal menstruation pattern is achieved in up to 100% of cases;^{4 19 24 26} however, adhesiolysis can result in lower pregnancy and live birth rates.^{19 20 24} Women who become pregnant after treatment are at high risk of obstetric complications, including miscarriage, premature labour, spontaneous uterine rupture, abnormal placentation, severe intrauterine growth retardation, and postpartum haemorrhage.^{24 27 28} Placenta accreta is the most common complication,²⁹ and delivery by caesarean section followed by hysterectomy is often necessary.^{24 29} It is, therefore, essential to inform patients about their risk of life threatening complications in pregnancy after treatment for intrauterine adhesions and to monitor and manage their pregnancies closely in hospitals.

Intrauterine adhesions can recur after treatment in patients with Asherman’s syndrome. The risk of recurrence seems to correlate with the severity of the intrauterine adhesions before treatment and is possibly associated with an innate predisposition to intrauterine adhesions.^{6 30} Methods of preventing further adhesions include physical barriers and pharmacological agents.³¹ Barrier methods work by separating the dissected adjacent uterine surfaces during the initial healing phase, when the risk of adhesion re-formation is highest.³¹ Techniques include the intrauterine contraceptive device,^{4 23 32} Foley catheter balloon,^{4 6 19 32} and amnion graft.³³ Pharmacological methods include treatment with oestrogen and progestogen, which stimulate regrowth of the endometrium.^{26 34} Two new pharmacological agents—hyaluronic acid and SprayGel (Confluent Surgical, Inc, Waltham, MA)—have been developed that act as a gel barrier in the uterine cavity and are then absorbed into the circulatory system for excretion.^{35 36} Although which preventative methods are most effective is under debate,^{3 32 37} postoperative prevention of further intrauterine adhesions is key for successful treatment of Asherman’s syndrome.

Patient outcome
Following hysteroscopy, adhesiolysis, and fitting of an intrauterine device worn for three months (to prevent recurrent adhesions), this patient returned to normal menstruation. She subsequently conceived within 4 months and had a normal delivery.

Cite this as: BMJ 2009;338:b2282

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent obtained.

References

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