A 41-year-old woman comes to the office due to irregular menstrual periods and intermittent milky discharge from both breasts for the past 6 months. During this time, she has also had vaginal dryness and dyspareunia. The patient has had no headaches, visual loss, weight changes, or hirsutism. She has had no prior medical problems and takes no medications except for over-the-counter vitamin supplements.
Blood pressure is 112/70 mm Hg and pulse is 66/min. BMI is 21 kg/m². Physical examination shows no abnormalities except mild expressive galactorrhea from both breasts.
Laboratory results are as follows:
Serum chemistry is within normal limits. MRI of the brain shows a 7-mm pituitary mass. The patient is very reluctant to start any treatment.
Which of the following is the patient at an increased risk of developing if her current condition is left untreated?

Question

A 41-year-old woman comes to the office due to irregular menstrual periods and intermittent milky discharge from both breasts for the past 6 months. During this time, she has also had vaginal dryness and dyspareunia. The patient has had no headaches, visual loss, weight changes, or hirsutism. She has had no prior medical problems and takes no medications except for over-the-counter vitamin supplements.
Blood pressure is 112/70 mm Hg and pulse is 66/min. BMI is 21 kg/m². Physical examination shows no abnormalities except mild expressive galactorrhea from both breasts.
Laboratory results are as follows:

Serum chemistry is within normal limits. MRI of the brain shows a 7-mm pituitary mass. The patient is very reluctant to start any treatment.
Which of the following is the patient at an increased risk of developing if her current condition is left untreated?

Quizplus · Accepted Answer

11ec193a_97a5_8f53_853d_0711a8e8f61c_MD0002_00 Treatment of lactotroph pituitary adenomas (prolactinomas) is dependent on tumor size and metabolic complications. A macroprolactinoma (>10 mm) typically requires treatment, but patients with a microprolactinoma (<10 mm) are usually treated only if they have specific indications (Table). Hyperprolactinemia suppresses gonadotropin secretion and causes hypogonadism in premenopausal women. The resultant low estrogen level can lead to infertility, amenorrhea or oligomenorrhea, vaginal dryness with dyspareunia, and hot flashes. Low estrogen levels are also a risk factor for rapid bone loss and osteoporosis. This patient has a microprolactinoma with significant hyperprolactinemia. Her vaginal symptoms suggest low estrogen levels. She should therefore receive treatment with a dopamine agonist (eg, cabergoline), which can lower prolactin production and mitigate hypoestrogenic complications. (Choice A) Endometrial cancer is usually caused by unopposed high estrogen rather than the low estrogen seen in this patient. (Choices C and E) Most microprolactinomas do not grow substantially over time and do not usually cause compression of surrounding tissues. Compressive effects (eg, panhypopituitarism, visual field defects) are more likely with macroprolactinomas, which are a more common presentation of hyperprolactinemia in men and postmenopausal women. (Choice D) Patients treated with higher doses of cabergoline (≥2 mg/week; eg, as used for Parkinson disease) have an increased risk for valvular heart disease and should be monitored with an echocardiogram every 2 years. This risk is not seen with the lower doses used for prolactinoma and is not an effect of untreated hyperprolactinemia. Educational objective: Hyperprolactinemia suppresses gonadotropin secretion and leads to hypogonadism, which leads to low estrogen levels with bone loss and osteoporosis in women. Microprolactinomas are generally slow growing with low risk of rapid enlargement. __________ References: Pituitary tumors: the prolactinomas. (http://www.ncbi.nlm.nih.gov/pubmed/19945024)

A 41-Year-Old Woman Comes to the Office Due to Irregular