A 23-year-old woman comes to the office with a month of milky discharge from both nipples. The patient's menstrual cycles have also been erratic for the past 3 months, and her libido is poor. She has mild breast tenderness but does not report any other symptoms. The patient has no medical issues but says she had a "nervous breakdown" a year ago, felt depressed, and did not leave the house for almost 2 months. She thought a neighbor was plotting to burn down her house, so she sat up many nights at the door watching for unusual activity. The patient was eventually treated and remains on medication. She has a family history of breast cancer, bipolar disorder, and Graves disease. She occasionally drinks alcohol, and smokes a half-pack of cigarettes per day. Laboratory studies show a prolactin level of 70 ng/mL (normal, 3-30 ng/mL) and a TSH of 3.0 mU/L. Urine pregnancy test is negative. Which of the following is most likely responsible for this patient's current symptoms?

Question

A 23-year-old woman comes to the office with a month of milky discharge from both nipples.  The patient's menstrual cycles have also been erratic for the past 3 months, and her libido is poor.  She has mild breast tenderness but does not report any other symptoms.  The patient has no medical issues but says she had a "nervous breakdown" a year ago, felt depressed, and did not leave the house for almost 2 months.  She thought a neighbor was plotting to burn down her house, so she sat up many nights at the door watching for unusual activity.  The patient was eventually treated and remains on medication.  She has a family history of breast cancer, bipolar disorder, and Graves disease.  She occasionally drinks alcohol, and smokes a half-pack of cigarettes per day.  Laboratory studies show a prolactin level of 70 ng/mL (normal, 3-30 ng/mL) and a TSH of 3.0 mU/L.  Urine pregnancy test is negative.  Which of the following is most likely responsible for this patient's current symptoms?

Quizplus · Accepted Answer

This patient's history of paranoia, social isolation, and disorganized behavior are suggestive of psychosis, and she is likely being treated with an antipsychotic medication. Antipsychotic medications cause dopamine blockade and because dopamine is a prolactin-inhibiting factor, the blockade of dopamine in the tuberoinfundibular pathway can lead to hyperprolactinemia and symptoms such as gynecomastia, galactorrhea, menstrual dysfunction, and decreased libido. Risperidone is a commonly used, second-generation antipsychotic that is known to have a high frequency of prolactin elevation and is likely responsible for this patient's symptoms. (Choice A) The antipsychotic aripiprazole is both an antagonist as well as a partial agonist of dopamine D2 receptors. Due to its partial agonism of dopamine, it is less likely to cause hyperprolactinemia. (Choice B) Galactocele is a benign milk collection in lactating women, usually due to a blocked duct. This patient's pregnancy test was negative, and there is no indication that she is breastfeeding. (Choice C) Hypothyroidism can predispose to hyperprolactinemia but typically presents with other complaints such as lethargy, dry skin, or cold intolerance, which this patient does not have. In addition, this woman's TSH is within normal range. (Choice D) Polycystic ovary syndrome (PCOS) is associated with increased androgen levels resulting in acne, hirsutism, and menstrual irregularities. It can occasionally cause an elevation in prolactin levels. This patient does not report symptoms of hyperandrogenism typical of PCOS. (Choice E) Prolactinomas are benign pituitary tumors that typically cause headaches and visual disturbances, which this woman does not have. They can cause very high prolactin levels (>200 ng/mL), whereas medication-related hyperprolactinemia is typically 25-100 ng/mL with levels seldom above 200 ng/mL. (Choice G) Valproate is an anticonvulsant used to treat bipolar disorder and seizures. It does not cause galactorrhea but is associated with adverse effects such as blood dyscrasias and liver toxicity. Educational objective: Antipsychotic medications can cause hyperprolactinemia secondary to their dopamine blockade effect. Risperidone has a high frequency of prolactin elevation. In comparison to antipsychotics, prolactinomas are capable of producing very high levels of prolactin (>200 ng/mL). References: Prolactin and dopamine: what is the connection? A review article. (http://www.ncbi.nlm.nih.gov/pubmed/18477617) Antipsychotic medication in children and adolescents: a descriptive review of the effects on prolactin level and associated side effects. (http://www.ncbi.nlm.nih.gov/pubmed/19702492)

A 23-Year-Old Woman Comes to the Office with a Month