History

1. 25 years old
2. Oligomenorrhoea(since 4 years, occurs once in 45 days with scanty flow. Last cycle was 4
months ago)
3. On antidepressants since 1 year( grief, insomnia)
4. Galactorrhoea (expressive since 5 months. Since 3 months, spontaneous)
5. No visual disturbance

Examination

1. BMI was 32 kg/m2,

2. BP was 130/80 mmHg
3. No goitre or hyper androgenic signs.
4. Prolactin level was 165 ng/ml (n = 5-23 ng/ml).
5. The MRI report is awaited.

1.What additional questions should be asked and examination done in this patient?

 Pregnancy
 Symptoms of low bone density( low calcium intake, eating disorders,back pain, easy
fractures)
 Drugs such as estrogen, neuroleptic drugs such as risperidone, metoclopramide,
antidepressant drugs, cimetidine, methyldopa, and verapamil
 headache, visual symptoms,
 symptoms of hypothyroidism,
 History of renal disease.
 Family history-Germline loss-of-function mutation

 chest wall injury

 chest wall injury
 signs of hypothyroidism
 hypogonadism

2. What additional diagnostic tests should be ordered as part of the work-up of galactorrhea and
amenorrhea in this patient?

 Studies should be performed to test for hypothyroidism and renal insufficiency

 MRI in drug-induced hyperprolactinemia Most drugs do not cause an elevation to
over 100 ng/mL. If the serum prolactin concentration is greater than 100 ng/mL, MRI
is done.

 If lesion found, secretion of other pituitary hormones should also be evaluated

 Serum prolactin (lactotroph adenomas)

 Insulin-like growth factor-1 (IGF-1) (somatotroph adenomas)

  Plasma corticotropin (ACTH) (corticotroph adenomas)

 Chronic renal failure — Hyperprolactinemia in chronic renal failure is due to

decreased clearance of prolactin
3. Treatment

 Lactotroph adenoma-dopamine agonist-cabergoline>bromocriptine

 After one month of therapy, the patient should be evaluated for side effects and
serum prolactin is measured.
 If the serum prolactin concentration is normal and no side effects have occurred, the
initial dose should be continued.
 If the serum prolactin concentration has not decreased to normal but no side effects
have occurred, the dose should be increased gradually
 If dopamine agonists have been unsuccessful,
1. transsphenoidal surgery or ovulation induction with clomiphene citrate can be
considered (for women wishing to become pregnant)
2. For women not pursuing pregnancy, estrogen and progesterone replacement
can be considered;

Drug-induced hyperprolactinemia

 discontinuing the drug as a trial.

 If discontinuation is not feasible, switching to a drug with a similar action that does
not cause hyperprolactinemia,
 adding estrogen or testosterone for the hypogonadal symptoms and/or low bone
mass, or cautious administration of a dopamine agonist