ABSENT PERIODS
A
24-year-old woman presents
with the absence
of periods for 9 months.
She started her periods at the age of 13 years and had a regular 28-day
cycle until 18 months ago. The
periods then became irregular, occurring every 2–3 months until they stopped completely. She has also had headaches for the last few months
and is not sure if this is related. She has
a regular sexual partner and uses condoms
for contraception. She has never been
pregnant. There is no previous
medical history of note.
She
works as a primary school teacher and drinks approximately 4 units of alcohol per week.
She does not smoke or use recreational drugs. She jogs and swims
in her spare time.
The
woman is of average build.
The blood pressure
and general observations are normal. The abdomen
is soft and non-tender and speculum and bimanual examination are unremarkable.
·
What is the diagnosis?
·
Are any further investigations indicated?
·
How would you manage this patient?
The
investigations show a high-prolactin and a space-occupying lesion in the pituitary
fossa in the region of the anterior
pituitary as detailed
in Figure 10.2. This is consistent with a pituitary adenoma (prolactinoma).
Prolactin should always be measured
in a woman with amenorrhoea. Care should be taken in interpreting the
results, as levels
up to 1000 mu/L
can be found
as a result of stress (even due to venepuncture), breast examination or in association with polycystic
ovarian syndrome). Above
1000 mu/L the usual
cause is a pituitary adenoma
(micro- or macroscopic).
Visual fields should be checked, as visual field
defects may be present with a large
tumour. The other important
investigation in any woman with amenorrhoea is a pregnancy
test, although with this history this would be very unlikely. (Prolactin
is also raised in pregnancy.)
Most prolactinomas respond to
medical treatment with bromocriptine or cabergoline. Maintaining the prolactin level
below 1000 mu/L causes
menstruation (and ovulation) to return in most
women. This can
be continued indefinitely or until pregnancy is achieved if the
presenting complaint is of infertility.
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