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?