doyoudig
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A 36 y/o woman presents to the office with a 1-year history of amenorrhea. she has also noticed occasional milk discharge form both breasts. she is not taking OCP or any other medications. the patient has a 7 y/o child which she has not breastfed since 9 months of age. PE shows expression of milk from both breasts. neck has diffused an enlarged nodule. pregnancy test is negative. Serum prolactin level is 80ng/ml (normal:4-30ng/ml). free thyroxin is 0.6 mU/dL(normal: o.8-1.8ng/dL), and thryoid-stimulating hormone is 36 mU/L (normal: 0.4-5 mU/L.
MRI of the head shows generalized pituitary enlargement. which of the following is the most appropriate management for this patient?
A. Bromocriptine
B. Cabergoline
C. radiotherapy
D. Transsphenoidal surgery
E. Thyroxine
Explain your ans Pls!!!!
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| sprint123
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| | 07/03/07 - 08:19 PM
2 of 3 forum leaders found this post helpful
| #2 |
Patient has hypothyroidism---->Increased TRH--->Stimulates Prolactin secretion---->Hyperprolactinemia
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| sprint123
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So I think the asnwer is E!
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| usmlestud
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| tolito
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yes, i agree with e.
one missing step
the increased TRH activates dopamine which activates prolactin secretion.
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| ssrpk
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the increased TRH antagonizes dopamine and thus increase prolactin secretion
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| elitoki
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Could someone explain the MRI finding?
I understand that primary hypothyroidism can increase level of TSH and TRH. And, it will decrease dopamine level and due to low dopamine will increase prolactin level. But...
Why or how can produce pituitary enlargement? 
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| sprint123
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OOPS!!! That's a very good point elitoki! I missed it!
What I can think is may be the patient has a pituitary macroadenoma producing both HYPERPROLACTINEMIA and Increased THYROTROPIN levels------
I think in this patient since the thyroxine level is low, the thyrotropin secreted from the pituitary adenoma is not good enough to stimulate thyroxine secretion---Interesting!
So the answer must be Trans-sphenoidal surgery??!!
Any comments?Wat's the answer doyoudig--Curious about it!
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| Justice
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C. radiotherapy
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| dr in trouble
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the answer shoud b surgery as in macroadenomas the medical and radian therapy follow surgery, the cause of low free thyroxine could be thyroid burn out due to excessive stimulation from TSH as the pt has diffuse nodular swelling in the neck.
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| dr19
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prolactin-secreting microadenoma--->bromocriptine
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| ssrpk
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well primary hypothyroidism will result in high TRH and this increase in TRH may be the reason for hyperplasia of thyrotropes.
i will stay with E
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| doyoudig
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Yes E is the Answer, D/t Lack of negative Feedback (i.e. Hyopthy --> Incr Sectretion of TSH/TRH which is the cause of the MRI findings
The DDx of Hyperprolact needs to be investigated 1st before going to Rx w/ Carbergoline (less SE than Bromo) and if Unresp or Compression Sx then Surgery is Next)
So R/o Causes 1st - Drugs, Hypothyroids...
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| young_doc
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Thyroxin is low, TSH is high. This is clearly primary hypothyroidism, which also explains the increased Prolactin.
The only thing that doesn't make sense is the "Generalized Pituitary enlargement"...which i didn't think we saw due to TRH stimulation in hypothyroidism?
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| cirus
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The ans is thyroxine
But i join dr in trouble with his doubt about the MRI finding, as it doesn't fit so anyone has any expl
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| hanwin
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Final Ans: thyroxine
TRH cause hyperplasia of thyrotrope---> generalized pituitary enlargement.
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