Critically appraise the management of a 27-year-old woman presenting with inappropriate galactorrhoea and secondary amenorrhoea. (20 marks)
Common mistakes
● Assuming that she has a prolactinoma – no definite cause has been provided
● Discussing the treatment of infertility
● Referring the patient to an endocrinologist – indicating that this is the best option and
therefore a gynaecologist should not manage her!
● Concentrating on history and physical examination – unnecessary to provide all the
details
● Failure to critically appraise your answer
A good answer will include some or all of these points
● There are many causes of galactorrhoea
● A good history to exclude some of these
● Physical examination to exclude disturbances in the visual field; thyroid gland enlargement; breast examination to confirm galactorrhoea
● Investigations to identify the cause of the galactorrhoea: hormone profile – TSH, FT4;
FSH, LH, skull X-ray – will only identify gross pathology. Best option is MRI of the skull,
especially the pituitary fossa; CT scan if necessary
● Treatment will depend on the cause and the wishes of the patient
● Primary concern amenorrhoea – treat appropriately
● Infertility coexisting – treat accordingly
● May need referral to neurosurgeons for surgery for prolactinomas
● Treatment for prolactinomas: bromocriptine; cabergoline; PCOS; osteoporosis
Sample answer
Inappropriate galactorrhoea is defined as milk production outside lactation. In some cases
there may not be an obvious cause, but often it may be due to hyperprolactinaemia. The combination of amenorrhoea and inappropriate galactorrhoea suggests that the patient may be
hyperprolactinaemic. In her management, possible causes of galactorrhoea should be
excluded before initiating treatment for the amenorrhoea.
Recognised causes of hyperprolactinaemia, such as drugs that inhibit dopamine production
or action (e.g. phenothiazides, benzodiazepines, steroids, antihypertensive agents, etc.) may
be established from directed questioning of the patient. In addition, symptoms of hypothyroidism, intracranial lesions (headaches, nausea, vomiting, visual field disturbances), chronic
renal failure and PCOS or stress may be excluded from the history. Although the history may
provide very useful information, it is important to recognise that the most common causes of
hyperprolactinaemia are pituitary prolactinomas and idiopathic hypersecretion, both of
which are more likely to be asymptomatic. Indeed, the two pathologies may be unrelated and
therefore symptoms of other causes of secondary amenorrhoea need to be excluded.
A physical examination may identify signs suggestive of the possible cause of either the
inappropriate galactorrhoea or amenorrhoea, or both. These will include visual field disturbances, thyroid enlargement, confirmation of galactorrhoea, features of PCOS (such as hirsutism) and genital tract abnormalities. A series of investigations is essential to diagnose the
causes of these problems. A hormone profile (TSH, FT4, FSH, LH and prolactin) will confirm
hyperprolactinaemia, if present, or other causes, e.g. hypothyroidism, PCOS, etc. To identify
prolactinomas, MRI of the skull, especially of the pituitary fossa, will be required. This offers a
better resolution to detect small microprolactinomas, but CT scanning is an equally good
alternative and, in the absence of these, an X-ray of the skull would be performed. Although
hormone assays may identify causes, normal values do not necessarily exclude them. Similarly,
microprolactinomas may not be defined easily from the radiological investigations. X-rays are
now considered crude screening methods for gross abnormality of the pituitary fossa or calcification in a craniopharyngioma.
The treatment of this patient will depend on the cause of either the amenorrhoea or the
galactorrhoea, or both. Where the causes are unrelated it may not be possible to treat them
concurrently, in which case the predominant concern must be treated first. Since most causes
of galactorrhoea due to hyperprolactinaemia are idiopathic or of the microprolactinoma varieties, the treatment of choice will initially be for this variety. The treatment of choice will be a
dopamine agonist, such as bromocriptine. This is effective in shrinking prolactinomas and
reducing prolactin levels in the idiopathic group. Attempts must be made to remove known
iatrogenic causes of hyperprolactinaemia, such as drugs, if possible. It is important to counsel
the patient on her fertility whilst she is taking bromocriptine. This may not be acceptable to
her because of side-effects, such as headaches. In this case, alternatives, such as cabergoline or
quinagolides, may be used.
For the macroadenomas, transphenoidal microsurgical excision is the treatment of choice.
One of the main consequences of hyperprolactinaemia is osteoporosis. This should be
addressed by instituting oestrogen therapy. This may be combined with bromocriptine. The
treatment of the patient’s amenorrhoea may be the combined oral contraceptive pill, but it
must be remembered that this can itself cause hyperprolactinaemia.
About the Author
