Pituitary Case: 28-year-old Woman with Amenorrhea and Nipple Discharge

00:01 Let's go on to another case.

00:03 A 28-year old woman is evaluated for amenhorrhea.

00:06 She stopped taking her oral contraceptive pill eight months ago in order to get pregnant.

00:12 Her menstrual cycle has not resumed.

00:15 She did have normal menses prior to the beginning of oral contraceptives four years ago.

00:22 She also complains of daily nipple discharge over the last six weeks.

00:27 Other than the oral contraceptive pill, she takes no other medications.

00:31 On exam, her vital signs are normal, but she has a white discharge from bilateral nipples.

00:38 Her thyroid, skin, and visual field exam are normal.

00:42 Labs are significant for a prolactin level of 86 nanograms per ml, a normal thyroid-stimulating hormone, and a negative pregnancy test.

00:53 The MRI for pituitary shows a nine millimeter pituitary mass.

00:58 What is the diagnosis? This young woman has secondary amenhorrhea, the production of abnormal breast milk or galactorrhea, an elevated prolactin levels, and a pituitary mass.

01:12 She most likely has a prolactinoma in her anterior pituitary causing secondary amenhorrhea, which is the cessation of menses, despite the presence of normal cycles after puberty.

01:23 Pituitary microadenomas that secrete excessive prolactin cause secondary amenhorrhea due to the inhibition of gonadotropin-releasing hormone in the hypothalamus.

01:34 We would treat these patients with dopamine agonists.

01:37 Bromocriptine is a good first-line agent because of its low cost.

01:41 Cabergoline is better tolerated however because tumor shrinkage is better, but unfortunately, it is more expensive.

01:50 Always check response to therapy by repeating a prolactin level in one month after commencing treatment.