Reproduction

Question 1

[case]

Answer 1

A 44-year old mother of two children presents to her GP worried that she hasn’t had a period for three months. She also reports occasional expression of milk from her breasts (galactorrhoea).

Question 2

What is the medical term for the absence of menstrual periods?

Answer 2

amenorrhoea -secondary

Question 3

What other questions would you like to ask?

Answer 3

Have you had any other symptoms? (e.g. early menopause) (hot flushes, sweats, sleep disturbance, vaginal dryness, urinary problems)

Have you done a pregnancy test? - first question

[Have you had any recent sexual activity?]

Have you had any headaches? (pituitary tumour)

Have you had any previous issues/problems affecting your thyroid? (hypothyroidism) - Have you noticed any changes in your weight? (weight loss for secondary amenorrhoea)

Have you been more tired recently?

Are you on any medication

Question 4

What is the significance of galactorrhoea?

Answer 4

galactorrhoea - has excess prolactin being produced

excess prolactin - hyperprolactinemia - inhibits kisspeptin

Question 5

Draw the female hypothalamo-pituitary-gonadal axis. Use this to help you plan what investigations would you like to perform.

Answer 5

hypothalamus - kisspeptin —> binds to kisspeptin receptors on GnRh neurones –> GnRh released into portal circulation –> acts on Gonadotrophs in the anterior pituitary –> FSH and LH release –> acts on ovaries to produce oestrogen/progesterone –> negative feedback via oestrogen/progesterone acting on APH and hypothalamus to reduce FSH/LH release (and kisspeptin release)

1. probably better to measure oestrogen given that it is diurnal and easier to measure
2. could also measure the levels of FSH/LH released into the circulation (has pulsatile release - harder)
3. MRI - to investigate whether or not there is a pituitary tumour. If there is a pituitary tumour - it could inhibit dopamine release which would allow access production of prolactin - leading to galactorrhoea.

Question 6

[results]

Answer 6

Urine pregnancy test (Beta human chorionic gonadotrophin): negative

Oestradiol: <70 pmol/L; low

LH: 0.5 IU/L; low

FSH: 0.8 IU/L; low

Prolactin: 36000 mU/L; very high

Question 7

Based on the clinical history, examination and investigations, what is the diagnosis?

Answer 7

tumour of lactotrophs - a prolactinoma

once you have confirmed very high level of prolactin, then MRI - to investigate whether or not there is a pituitary tumour.