Case (73)

[Dr.Habiib]

 Ceebla is 35 year-old nurse. She has been married for 7 years. Ceebla`s menstrual period started when she was 12 years and were regular until 10 months ago. At that time, her periods became irregular and then ceased (amenorrhea), and a milky substance was leaking from her breasts. Ceebla was very anxious because she and her husband had been talking about trying to have a child.
 Her gynecologist reported those normal pelvic organs (uterus, fallopian tube, and ovary) but he was able to express milk from her breast.
  Based on her symptoms and physical examination, her doctor suspected that ceebla had abnormal increase of hormone.
  He ordered MRI scan for her brain. The scan showed a 2cm mass in her pituitary gland.

Laboratory test showing:
Prolactin: 86ng/ml  (Normal 5-25ng/ml)
FSH: 5mU/ml (Normal 5-20mU/ml)
Pregnancy test: negative.
 While Ceebla was awaiting surgery to remove the mass a drug was initiated which decreased serum of prolactin level to 20ng/ml.
After the adenoma was removed ceebla galactorrhoea stopped, her menstrual periods resumed and she is pregnant now.



Questions:
1. What is your diagnosis of this abnormal hormone?
2. How this hormone is regulated?
3. What are factors increase this hormone secretion leading to an increase in the serum level?
4. Why did Ceebla has a galactorrhea?
5. Why were her menstrual cycles irregular?
6. What was the significance of her FSH level?
7. What drug was Ceebla given to lower her serum of this hormone level?
8. What is the mechanism action of this drug?

[Dr.Noora]

1.What is your diagnosis of this abnormal hormone?

Prolactenimia : wich usually caused by prolactinoma, a benign tumor in the pituitary gland.

2. How this hormone is regulated?

Prolactin is a protein hormone of the anterior pituitary gland that was originally named for its ability to promote lactation in response to the suckling stimulus of hungry young mammals,It is synthesised and secreted by lactotrope cells in the adenohypophysis (anterior pituitary gland). It is also produced in other tissues including the breast and the decidua.
Pituitary prolactin secretion is regulated by neuroendocrine neurons in the hypothalamus, most importantly by neurosecretory dopamine neurons of the arcuate nucleus, which inhibit prolactin secretion. Thyrotropin-releasing factor has a stimulatory effect on prolactin release.
Vasoactive intestinal peptide and peptide histidine isoleucine help to regulate prolactin secretion in humans.

3. What are factors increase this hormone secretion leading to an increase in the serum level?

Prolactinemia has many causes, some of which include the following:
•   Tumors (usually benign, or not cancerous), especially tumors of the pituitary gland, which is located in the brain
•   Medicines such as hormones, antidepressants, blood pressure medicines and certain tranquilizers
•   Herbal supplements such as nettle, fennel, blessed thistle, anise and fenugreek seed
•   Drugs such as marijuana and opiates
•   Pregnancy
•   Clothing that irritates the breasts (such as scratchy wool shirts or bras that don't fit well)
•   Doing very frequent breast self-exams (daily exams)
•   Stimulation of the breast during sexual activity
•   Kidney disease
•   Oral contraceptives
•   An underactive thyroid (also called hypothyroidism), which is a gland that produces hormones
Sometimes the cause of Prolatinemia  can't be found.Idiopathic


4. Why did Ceebla has a galactorrhea?

She was having Galatorrhea because of prolactinoma, a benign tumor in her pituitary gland

5. Why were her menstrual cycles irregular?

Prolactin inhibits two hormones necessary for ovulation: follicle stimulating hormone (FSH) and gonadotropin releasing hormone (GnRH). Both of these hormones are responsible for helping the eggs to develop and mature in the ovaries, so that they can be released during ovulation. When there excess prolactin in the bloodstream, ovulation is not triggered, and it will be unable to menstruate or  to have regular cycle and evan to become pregnant.

6. What was the significance of her FSH level?

In this particular case FSH will be significant for working up for Amenorrhea. someone may also think that prolactinoma may release some other hormones which is unlikely for FSH, remember the most commonly associated hormone with Prolactinoma is growth hormone.

7. What drug was Ceebla given to lower her serum of this hormone level?

Bromocriptine or cabergoline .but Bromocriptine is the most commonly used drug. Most of the patients  respond well to these drugs, although large prolactinomas are more difficult to treat and they may need surgical removal

8. What is the mechanism action of this drug?

Bromocriptine is in a class of medications called dopamine receptor agonists. It treats hyperprolactinemia by decreasing the amount of prolactin in the body. It treats acromegaly by decreasing the amount of growth hormone in the body. Also It treats Parkinson's disease by stimulating the nerves that control movement.

[Dr.Habiib]

 Excellent  Dr.Noora  you got 100%, thank you very much.
 
   You got 15 marks with no discussion.

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