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Snapshot
  • A 36-year-old woman presents to the physician with complaint of nipple discharge. She states that she has observed a milky discharge coming from both of her nipples for the past 3 weeks. She notes that other abnormal symptoms she has experienced include intermittent headaches and decreased libido. Physical examination reveals a severe visual field defect, depicted in the image.
Introduction
  • Overview
    • a prolactinoma is a non-cancerous pituitary tumor that overproduces the hormone prolactin
      • treatment is usually with medication to restore a normal prolactin level or surgical resection
  • Epidemiology
    • incidence
      • most common pituitary adenoma (40% of all pituitary adenomas)
    • demographics
      • more common in women than men
      • peak prevalence in women ages 25-34 years
    • location
      • pituitary gland
        • lateral parts of anterior pituitary are most common sites
  • Pathophysiology
    • prolactinomas arise from monoclonal expansion of pituitary lactotrophs
      • results in excess synthesis and secretion of prolactin
        • ↑ prolactin inhibits GnRH secretion, leading to ↓ LH and FSH secretion
      • can cause hypopituitarism from mass effect
Presentation
  • Symptoms 
    • headache
    • visual changes
      • visual field deficits
      • blurred vision
      • ↓ visual acuity
    • signs of hyperprolactinemia in women
      • amenorrhea or oligomenorrhea
      • infertility
      • loss of libido
      • galactorrhea
    • signs of hyperprolactinemia in men
      • loss of libido
      • impotence
      • erectile dysfunction
  • Physical exam
    • bilateral hemianopsia 
      • mass lesion disrupts visual pathways crossing in the optic chiasm 
    • galactorrhea
    • gynecomastia
Imaging
  • MRI or CT scan of the pituitary hypothalamic area
    • indications
      • determine if a mass lesion is present
Studies
  • Serum prolactin levels
    • measure on 1 or more occassions
  • Serum pregnancy test
    • rule out pregnancy as the cause of secondary amenorrhea in reproductive-aged females
  • Serum TSH
    • rule out the possibility of ↑ prolactin level secondary to an elevated TRH level
  • Serum testosterone levels
    • measure in men presenting with symptoms of hypogonadism
Treatment
  • Medical
    • bromocriptine or cabergoline (dopamine agonists)
      • indications
        • first-line treatment
          • dopamine suppresses prolactin secretion
  • Surgical
    • surgical resection
      • indications
        • patients who cannot tolerate or do not wish to take dopamine agonists
        • patients who do not respond to medical treatment or show progression after an initial response to medical treatment
Complications
  • Cranial nerve palsies due to mass effect
  • Infertility
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.EC.15.75) A 34-year-old woman presents to her OB/GYN with complaints of missing her last 3 periods as well as intermittent spontaneous milky-white nipple discharge bilaterally for the past 3 months. Vital signs are stable and within normal limits. Neurologic examination is without abnormality, including normal visual fields. Serology and MRI of the brain are ordered, with results pending. Which of the following sets of laboratory results would be expected in this patient? Review Topic | Tested Concept

QID: 106775
1

Decreased prolactin, decreased FSH, decreased LH

5%

(3/63)

2

Decreased prolactin, increased FSH, increased LH

2%

(1/63)

3

Increased prolactin, decreased FSH, increased LH

6%

(4/63)

4

Increased prolactin, decreased FSH, decreased LH

75%

(47/63)

5

Increased prolactin, increased FSH, increased LH

11%

(7/63)

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(M1.EC.13.11) A 45-year-old male presents to the hospital complaining of frequent headaches and a decreased libido. During the physical exam, the patient also states that he has recently been experiencing vision problems. The patient is suffering from what type of adenoma? Review Topic | Tested Concept

QID: 100312
1

Somatotroph

3%

(6/201)

2

Lactotroph

77%

(154/201)

3

Corticotroph

2%

(5/201)

4

Thyrotroph

2%

(4/201)

5

Gonadotroph

15%

(30/201)

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(M1.EC.13.7) A 29-year-old female visits her gynecologist because of an inability to conceive with her husband. Past medical history reveals that she has been amenorrheic for several months, and she complains of frequent white nipple discharge. Urine tests for beta-HCG are negative. A receptor agonist for which of the following neurotransmitters would be most likely to treat her condition: Review Topic | Tested Concept

QID: 100507
1

Somatostatin

12%

(2/17)

2

Dopamine

88%

(15/17)

3

Vasopressin

0%

(0/17)

4

Insulin

0%

(0/17)

5

Serotonin

0%

(0/17)

L 3 E

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Topic COMMENTS (11)
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