A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. She has no other major medical problems. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Serum prolactin is ordered and the result is elevated at 47ng/mL.
What is the next step in management?
Modest increased in serum prolactin should be reevaluated at least once prior to ordering an imaging study, because prolactin can be transiently increased by many factors such as stress, breast stimulation, or eating. If it is persistently elevated, she should undergo MRI of the pituitary. It is also important to check a TSH to rule out thyroid disease and an FSH to rule out ovarian failure (as a cause of the amenorrhea). There is no indication to refer her to a breast surgeon or to check a HbA1c.
Which of the following classes of medication is also a possible cause of galactorrhea?
Amenorrhea and galactorrhea may be seen when something causes an increase in prolactin secretion or action. The differential diagnosis involves several possible causes. Excessive estrogens, such as with birth control pills, can reduce PIF, thus raising serum prolactin level. Similarly, intensive suckling during lactation can activate the reflex arc that results in hyperprolactinemia. Many antipsychotic medications, especially the phenothiazines, are also known to have mammotropic properties. Hypothyroidism appears to cause galactorrhea secondary to thyrotropinreleasing hormone (TRH) stimulation of prolactin release. When prolactin levels are persistently elevated without obvious cause (eg, in breastfeeding), evaluation for pituitary adenoma becomes necessary.
Which of the following pubertal events in girls is not estrogen dependent?
The presence of estrogen in a pubertal girl stimulates the formation of secondary sex characteristics, including development of breasts, production of cervical mucus, and vaginal cornification. As estrogen levels increase, menses begins and ovulation is maintained for several decades. Ovarian estrogen production late in puberty is at least in part responsible for termination of the pubertal growth spurt, thereby determining adult height. Decreasing levels of estrogen are associated with lower frequency of ovulation, eventually leading to menopause. Hair growth during puberty is caused by androgens from the adrenal gland and, later, the ovary.
An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility.
You should tell the couple which of the following?
Semen analysis is an important part of an infertility evaluation. This specimen should ideally be collected at a doctor’s office by masturbation following at least 48 hours of abstinence. Because of the variability in semen specimens from the same person, at least two samples should be collected over 1 to 2 weeks during the course of an investigation for infertility. A normal semen analysis will demonstrate at least 20 million sperm per milliliter, over 60% of the sperm with a normal shape, a volume of between 2 mL and 6 mL, and at least 50% of the sperm with progressive forward motility.
A 21-year-old woman presents to you for management of menstrual migraines. She has no other medical problems, does not smoke, and does not take any medications routinely. Her periods are regular and last 5 days. She says the flow is moderate and she does not have dysmenorrhea. She is sexually active with her partner of 1 year, and she uses condoms for contraception. She says she develops a debilitating migraine for the first 2 days of her period every month. She describes her headaches as unilateral, throbbing, and associated with nausea and photophobia. She has missed work due to these symptoms.
What is the best next step in management of her migraines?
Menstrual migraines occur in 8% to 14% of women. They occur exclusively during menses, and are absent during other times of the cycle. They are thought to be caused by hormonal fluctuations, specifically the premenstrual decline in estrogen. Use of combined oral contraceptives stabilizes these hormone fluctuations, and provides relief for many women. There is no indication for narcotics, and continuous NSAIDs may cause gastrointestinal side effects. Referral to a neurologist for consideration of abortive treatments such as triptans may be indicated if the patient fails other therapies.
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