A 29-year-old lady comes to the hospital for complaints of oligomenorrhea for past 3 years. She attained menarche at 14 years and has had regular cycles since then. Over the last three years, she has gained 8–9 kilos of weight gradually. She has no complaints suggestive of galactorrhea, hot flashes or symptoms suggestive of thyroid dysfunction. She has been married for 3 years and wants to plan a pregnancy soon. Her last menstrual period was 15 days ago. She suffers from dyspepsia for which she uses pantoprazole and domperidone tablets 4–5 times a week. Her family has a history of thyroid dysfunction. On examination, she has a body mass index of 28.5 kg/m2. On general examination, she has grade 2 goiter, acanthosis, modified Ferriman–Gallwey score of 12/36 and expressive galactorrhea unnoticed before. Clinical examina- tion is not suggestive of any other illness like hypothyroidism or thyrotoxicosis, Cushing’s syndrome or acromegaly. Confrontation test is normal. Skin and ankle jerk normal.
Galactorrhea may be overlooked unless actively elicited.
Laboratory Examination Reveals Thyroid-stimulating hormone (TSH) 2.5 micro IU/L. Total T4 10 mg/dL, prolactin 160 ng/mL, urine pregnancy test negative. Ultrasound pelvis shows ovarian volume 12 cm3 with numerous cysts in both ovaries peripherally. A diagnosis of hyperprolactinemia, probably drug induced is made.
How is the case 1 patient managed?
Medicine
Hyperprolactinemia due to any cause can present with menstrual irregularities with galactorrhea. Most drug induced hyperprolactinemia are in the range of 25–100 ng/mL although dopamine antagonists like risperidone, metoclopramide can cause elevations up to 200 ng/mL. The patient is asked to stop the medications and repeat the assay. Caution must be exercised if the drug involved is antipsychotic medication before stopping. The repeat prolactin in our patient is 130 ng/mL.
As the prolactin levels do not normalize after discontinuation of the drug,
magnetic resonance imaging of the hypothalamic pituitary region with dynamic contrast is obtained which reveals a 9 mm microadenoma in the anterior pituitary.
A revised diagnosis of microprolactinoma is made.
Acromegaly can rarely be a cause of galactorrhea with patients with normal prolactin levels.
Numerous drugs available over-the-counter can increase prolactin levels. A detailed history always helps.
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