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Bis

A 31-year-old woman comes to the clinic because of "not having a period for over a year, white discharge from both nipples, and severe frontal headaches of 2 years duration". Evaluation reveals a follicle-stimulating hormone (FSH) level of 6.0 mIU/mL, basal serum prolactin level of 82 ng/mL, and thyroid-stimulating hormone (TSH) of 19 micro-U/mL (normal ranges: FSH 2-20 mIU/mL, prolactin, <20 ng/mL, TSH, 0.5-5.0 microU/mL). An MRI reveals pituitary enlargement with a mass measuring 13 mm in diameter. The next step in the management of this patient is

A. evaluation of other pituitary hormones
B. formal visual field testing
C. referral to a neurosurgeon
D. therapy with bromocriptine
E. therapy with levothyroxine

Why?

nb

"A"

graftmd

answer is C
because you already know that there is a mass, you don't treat the mass with meds because you don't know what it is, so you need to refere to neurosurgery for transsphenoidal biopsy and possible remowal

notty - nottyknight4u

i will go with C too. if a pit mass is more than 1 cm, next u do is reffer to neurosurgeon

nz img

Answer = D
Mass = prolactinoma. Medical therapy = treatment of first choice unless visual fields severly compromised or mass is undergoing apoplexy. Most respond to bromocriptine. Non-responders may require trans-sphenoidal resection. Check CMDT as reference.

Bis

any other opinion?

Ku

why not B . testing the visual fields to decide between medical or surgical treatment.
what do you think guys?

Bis

few people animated to answer, but correct ans is E

nz img

Seriously? I hate trick questions...grrrr

bis

The correct answer is E. Prolactin, unlike other anterior pituitary hormones, is primarily under tonic inhibition by dopamine secreted from the hypothalamus. Prolactin release can be stimulated by many factors including thyrotropin-releasing hormone (TRH). Because TRH is increased in primary hypothyroidism, the circulating TSH (not TRH) should be measured in all women who have amenorrhea or galactorrhea, or both, to exclude hypothyroidism. Increased TSH levels should be presumed to result from primary hypothyroidism. Many reports have documented that primary hypothyroidism can mimic a pituitary tumor and can lead to profound pituitary enlargement, because of the hypertrophy of thyrotrophs. After treatment with levothyroxine, the enlargement of the pituitary should subside and the patient should become euthyroid.