Case history
Case history #1
A 27-year-old woman presents with amenorrhoea. She had been taking the combined oral contraceptive pill for the last 9 years, stopping this 11 months ago. She is otherwise healthy, but on physical examination she has bilateral galactorrhoea. Laboratory work-up reveals an elevated prolactin level of 3000 mIU/L (150 micrograms/L). Normal prolactin levels are up to 500 mIU/L (25 micrograms/L). She also had low-normal gonadotrophin (luteinising hormone [LH], follicle-stimulating hormone [FSH]) levels. Magnetic resonance imaging (MRI) examination of the pituitary sellar region depicts a 6 mm right-sided pituitary mass, with no suprasellar or parasellar extension.
Case history #2
A 45-year-old man presents with loss of libido and some erectile dysfunction. He is otherwise healthy. On physical examination he has mild bilateral gynaecomastia and normal testes. Laboratory work-up reveals a highly elevated prolactin level of 46,000 mIU/L (2300 micrograms/L). Normal prolactin levels are up to 300 mIU/L (15 micrograms/L). He also has low testosterone, LH, and FSH levels. MRI examination of the pituitary sella depicts a large 32 mm pituitary macroadenoma with suprasellar extension and optic chiasmal compression. Visual field assessment reveals bi-temporal hemianopia.
Other presentations
Prolactinomas, particularly where they are large tumours, can present with sudden headache, syncope, vomiting, fever, and visual impairment. All these symptoms may occur in the setting of pituitary apoplexy (a clinical syndrome resulting from acute haemorrhagic or ischaemic infarction of a pituitary adenoma). Occasionally, prolactinomas are incidentally detected during imaging evaluation (computed tomography or magnetic resonance imaging) of the brain for other unrelated medical conditions. Infrequently, prolactinoma may be a component of the familial syndrome of multiple endocrine neoplasia syndrome type 1, together with primary hyperparathyroidism and neuroendocrine tumours, most commonly in the gastrointestinal tract.
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