A 31-year-old woman underwent dilation and curettage for retained products of conception 7 months ago. She now has severe cyclical lower abdominal pain every month at the expected time of menses, but only spotting occurs. Hormonal profile, including FSH, LH, estradiol, and thyroid function, is normal. What is the most appropriate next step?

• A Start combined oral contraceptives for presumed chronic anovulation
• B GnRH agonist therapy for suspected endometriosis
• C Serum beta-hCG and pelvic ultrasound for ectopic pregnancy
• D Diagnostic hysteroscopy with adhesiolysis ✓

Explanation

Cyclical pain with absent or scanty flow after uterine curettage and a completely normal endocrine profile is classic for Asherman syndrome, where intrauterine synechiae obstruct menstrual outflow while the ovaries remain functional. Hysteroscopy is both diagnostic and therapeutic, allowing division of adhesions. Normal gonadotropins and estradiol exclude ovarian failure, and the cyclical timing argues against pregnancy or endometriosis, which typically produces pain that is less tightly linked to expected menses.

Reference: Berek and Novak's Gynecology, 16th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.