QUESTION 1 A 30-year old female comes for an office visit to her family doctor b

Question

QUESTION 1

A 30-year old female comes for an office visit to her family doctor because her breasts produce milk since almost a month ago.  She is a single woman and never married before.  She has no steady boy friend at this time, and have no sexual intercourse since a year ago.   She claims that sometimes she has this massive headache that comes and goes since 5 years ago, and for that she only took over the counter medication such as Tylenol pm® that she also said helps her to sleep.  She feels like her vision is not normal and the glasses the optometrist prescribed 2 months ago doesn't suit her.  She sometimes see double vision and because of that she could not read for more than 10 minutes, because then she will experience blurriness and her eyes got "tired".  She also complains of general tiredness, and she does not have the energy to do the activities she had in the past such as: hiking, jogging or bicycling.  Her menstruation becomes irregular and less frequent. Her last menstruation was 6 months ago.  Family history is unremarkable.  No other direct family members have had inappropriate breast milk production.

Physical exam:

Temperature: 37o Celsius (normal: 36.10-37.20)Blood pressure: 120/80 mmHg (normal: 120/80 mmHg)heart rate: 75 beat/minute (normal 60-100 x/minute)respiratory rate: 15/minute (normal 12 – 20 x/minute)A slightly obese looking woman, with normal insight into place, time and people. Upon inspection, her eyes looks normal from the outside, she could read the book I gave, and could recognize how many fingers I showed her to each of her eye.Heart: heart sounds regular, no murmurs.  No heart enlargementLung: clear on auscultation.Her breast looks normal upon inspection except there is milk discharged from both nipples, no blood observed.  No pain on palpation.Other physical exam is normal.

1) what are the possible diagnoses (differential diagnoses)
2) explanation of pathophysiology of each of the differential diagnoses

Explanation / Answer

QUESTION 1 - The symptoms of women are similar to the disease called prolactinoma , A prolactinoma is a benign tumour (non-cancerous swelling) in the pituitary gland. Prolactinomas make large amounts of a hormone called prolactin.

~ High levels of prolactin in the blood can cause various symptoms. The symptoms differ slightly between men, women and children.

Women may have:

Men may have:

How is prolactinoma diagnosed?

The diagnosis may be suspected from the symptoms. Women tend to be diagnosed earlier than men, because a change in the woman's periods is an early symptom and is easily noticed. Some prolactinomas are diagnosed by chance, if you have tests for another reason. If a prolactinoma is suspected, you may be offered several tests.

Blood tests

A blood sample to check the level of prolactin in the blood. If a high prolactin level is found, you may be asked to have a repeat test. This is because prolactin levels can be affected by many other things in the body, such as sleep or stress. It may help to take the blood sample when you are reasonably rested and have been awake for at least two hours.The normal level of prolactin is less than 400 mU/L. A very high prolactin level (>5000 mU/L) usually means that a prolactinoma is present.

Eye tests

Eye tests will assess if the tumour is pressing on the optic nerve - this includes a test of visual fields.

Scans

A magnetic resonance imaging (MRI) scan or a computed tomography (CT) scan can show the size of the tumour. A bone density scan may be advised for some patients, to check whether they are at risk of 'thinning' of the bones (osteoporosis), which is a possible complication.

Pathophysiology of Prolactinoma

Prolactinomas are anterior pituitary lactotroph tumours. Hypersecretion of prolactin causes secondary hypogonadism via its inhibitory effects on gonadotrophin-releasing hormone and pituitary gonadotrophins. Dopamine is transported from the hypothalamus to the anterior pituitary by hypophysial portal vessels where it inhibits prolactin secretion via dopamine receptors expressed by lactotrophs. Therefore, disruption of dopamine secretion or transport to the portal vessels can lead to hyperprolactinaemia.

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