A 28-year-old woman from Mumbai presents with secondary amenorrhea for 8 months. She reports a normal menstrual history until 10 months ago, when she underwent a therapeutic abortion followed by uterine curettage for retained products of conception. On examination, she is afebrile with normal vital signs. Pelvic examination is unremarkable. Serum β-hCG is negative. Pelvic ultrasound shows a normal-sized uterus with a thin endometrial echo (2 mm) and no fluid collection. Serum FSH is 8 mIU/mL and LH is 6 mIU/mL. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Asherman Syndrome ### Pathognomonic Clinical Features **Asherman syndrome** (intrauterine adhesions) is characterized by: - **Secondary amenorrhea** following uterine instrumentation (D&C, curettage, abortion) - **Normal ovarian function** (normal FSH/LH, normal estradiol) - **Thin or absent endometrial echo** on ultrasound - **Normal-sized uterus** with no obvious pathology on basic imaging **Key Point:** The critical diagnostic clue is the combination of **amenorrhea + recent uterine instrumentation + thin endometrium + normal gonadotropins**. The ovaries are intact; the problem is intrauterine adhesions preventing endometrial growth and shedding. ### Why This Patient Has Asherman Syndrome 1. **Temporal relationship:** Amenorrhea began immediately after therapeutic abortion and curettage for retained products—classic trigger for adhesion formation. 2. **Normal gonadotropins:** FSH 8 mIU/mL and LH 6 mIU/mL are normal, indicating the hypothalamic-pituitary-ovarian axis is functioning. 3. **Thin endometrium:** 2 mm endometrial echo suggests fibrosis and adhesions, not a thick secretory endometrium. 4. **Negative β-hCG:** Rules out pregnancy as the cause of amenorrhea. 5. **No fever or pelvic fluid:** Rules out acute endometritis or pyometra. **Clinical Pearl:** Asherman syndrome is often missed because basic ultrasound may appear "normal" (no obvious mass or fluid). The key is recognizing the **thin endometrium in the context of prior instrumentation**. ### Diagnostic Approach ```mermaid flowchart TD A[Secondary Amenorrhea]:::outcome --> B{Recent Uterine Instrumentation?}:::decision B -->|No| C[Other Causes]:::outcome B -->|Yes| D{FSH/LH Normal?}:::decision D -->|No| E[Ovarian Failure]:::outcome D -->|Yes| F{Endometrial Thickness?}:::decision F -->|Thin/Absent| G[Asherman Syndrome]:::action F -->|Normal| H[Other Intrauterine Pathology]:::outcome ``` **High-Yield:** **Asherman = Amenorrhea + Abortion/Curettage + Adhesions**. Diagnosis confirmed by hysteroscopy (gold standard), which shows adhesions and allows therapeutic lysis. **Mnemonic:** **CURETTAGE** → **Asherman** = Curettage Uterine Trauma Endometrial adhesions Retained products Trauma Adhesions Gynecological Endometrial loss [cite:Jeffcoate's Principles of Gynaecology 8e Ch 12]