If bleeding does not occur, then the patient most likely has outflow tract obstruction - either Asherman's syndrome or cervical stenosis. The other approach is to perform an FSH level. If the FSH is normal, it is still a good idea to proceed with the course of estrogen and progestin as described above. The next step in the women that do not bleed after the combined hormonal regimen is either hysterosalpingography or hysteroscopy . If adhesions are found, they should be hysteroscopically lysed if the patient is desirous of pregnancy or menses.
Intrauterine adhesions are rare in the absence of a history of pelvic infection or curettage.
Therefore, if the pelvic exam is normal and the history is not consistent with development of adhesions, consideration can be given to skipping the estrogen-progestin step. This should not be drawn for at least 2 weeks after the estrogen-progestin regimen is completed so that the level is not affected by the exogenous estrogen. Midcycle FSH peak levels in ovulatory cycles should not be this high. FSH levels that are in the menopausal range should be checked at least once again in about 4 weeks. An estradiol level can be checked as well for further confirmation.