A 29-year-old woman comes to the physician because of recurrent headaches for the past 3 weeks. She describes her headaches as bifrontal and throbbing. She denies decreased vision, vomiting, fever, or head injury. Her stress level has increased over the past few weeks after she was laid off from her job. She has a history of migraine headaches as a teenager. She does not use tobacco or drink alcohol. She takes no medications. She stopped having menstrual periods after a progesterone-containing intra-uterine device was placed 18 months ago.
Examination, including neurologic examination, shows no abnormalities.
Complete blood count, chemistry profile, thyrotropin (TSH), and liver function tests are all within normal limits.
MRI of the brain shows a 7 mm hypointense mass in the pituitary without stalk deviation.
Which of the following is the most appropriate next step?

Question

A 29-year-old woman comes to the physician because of recurrent headaches for the past 3 weeks.  She describes her headaches as bifrontal and throbbing.  She denies decreased vision, vomiting, fever, or head injury.  Her stress level has increased over the past few weeks after she was laid off from her job.  She has a history of migraine headaches as a teenager.  She does not use tobacco or drink alcohol.  She takes no medications.  She stopped having menstrual periods after a progesterone-containing intra-uterine device was placed 18 months ago.
Examination, including neurologic examination, shows no abnormalities.
Complete blood count, chemistry profile, thyrotropin (TSH), and liver function tests are all within normal limits.
MRI of the brain shows a 7 mm hypointense mass in the pituitary without stalk deviation.
Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

11ec193a_97aa_bf82_853d_0925ed290672_MD0002_00 Pituitary incidentalomas occur in up to 10% of patients undergoing MRI for unrelated reasons. Lesions < 10 mm require careful clinical evaluation to look for pituitary hormonal hyperfunction. If there are no clinical features of pituitary hormonal hyperfunction, then the most cost effective strategy is to measure only prolactin levels. Small lesions (2-4 mm) require no further testing, while lesions 5-9 mm usually require follow-up MRI in 12 months to document a lack of growth (Choice D). Lesions > 10 mm should be evaluated with biochemical testing for both pituitary hormonal hyperfunction/hypofunction (e.g., Cushing's, acromegaly, and prolactin) and formal visual field/acuity testing (Choice A). Most pituitary masses do not grow rapidly over time. Lesions without mass effect or hormonal dysfunction can be safely followed with periodic clinical, biochemical, and radiological evaluation. Surgery is considered for macroadenomas with hormonal dysfunction or tumor mass effect, except for prolactinoma where medical therapy is effective (Choice C). (Choice B) Cosyntropin stimulation test screens for adrenal insufficiency. Small pituitary lesions rarely cause adrenal insufficiency and do not require testing. This patient's normal laboratory tests and vital signs also make this less likely. Educational objective: Pituitary incidentalomas measuring < 10 mm usually do not cause visual defects or pituitary hypofunction. Patients with small (< 10 mm) pituitary lesions only require monitoring with prolactin levels if there is no clinical evidence of pituitary hormonal hypersecretion. __________ References: Natural history of nonfunctioning pituitary adenomas and incidentalomas: a systematic review and metaanalysis (http://www.ncbi.nlm.nih.gov/pubmed/21474687) Pituitary incidentaloma: an endocrine society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/21474686)

A 29-Year-Old Woman Comes to the Physician Because of Recurrent