Problem
A 40-year-old woman is presenting to you with bilateral galactorrhea (milky nipple discharge). She tells you that she has never been pregnant and had initially presented at the age of 25 years with menometrorraghia (dysfunctional uterine bleeding) and bilateral galactorrhea, while being on oral contraceptives.She also reports recently having had more frequent bouts of moderate abdominal pain.
She reports having had normal puberty, and she deniessuffering from headaches, visual disturbances, weight or body changes, polyuria, hirsutism, or acne. Her history revealed that she has been on a high dose oral contraceptive pill the majority of her life since puberty. She had a pregnancy test done at her annual doctor's visit 3 months ago, and has not been sexually active since then.
Below are the initial laboratory findings:
Prolactin: 3,000 pmol/l (normal 165-1,009 pmol/l)
FSH: 19.2 IU/l (normal 4-13 IU/l)
LH: 0.6 IU/l (normal 1-18 IU/l)
Estradiol: 3,851.0 pmol/l (<1,094.0 pmol/l)
ACTH: 2.9 pmol/l (normal 1.1-5.9 pmol/l)
8 AM cortisol: 510.4 nmol/l (normal 165.5-634.6 nmol/l)
Glycoprotein subunit α* 0.8 µg/l (normal 0.04-0.38 µg/l)
TSH: 3.3 mIU/l (normal 0.39-4.6 mIU/l)
Free T4: 11.6 pmol/l (normal 10.3-34.7 pmol/l
IGF-1: 33.7 nmol/l (normal 18.1-53.7 nmol/l)
Glycoprotein hormone α is a shared subunit that is part of the heterodimeric structure for the hormones hCG, LH, FSH, and TSH
• Based on her symptoms and lab tests, what additional blood tests would you want to order? What more would you want to know from his medical history or know more about her symptoms, in general?
• What is your suspected diagnosis and why? Where do you hypothesize the origin of the dysfunction is and how would you test for this? What treatment(s), both pharmaceutical and lifestyle, do you recommend for this patient and what are you monitoring over time?