CASE 7: SECONDARY AMENORRHEA: HYPERPROLACTINEMIA

CASE 7
28 year old, single, nulligravid, gym instructor, complains of irregular menses. LMP: February 1 wk, 2013 PMP: Dec, 3 wk
2012. She was prescribed with medroxyprogesterone actetate last year, which she took for 3 months. She had regular menses
then. A month ago, she self-medicated with MPA 10 mg/day for 10 days but it has been 2 weeks since and she has not
menstruated yet. The patient denies any sexual contact. PPE: Hymen: intact; Rectal exam; cervix – firm long: Uterus – normal
size; adnexa – no mass / tenderness
Continuation from Case 06 as to the other causes of secondary
amenorrhea from Cervix, Uterus, Ovaries, Pituitary & Hypothalamus:
Pituitary
Tumors:
Sheehan’s syndrome
 CC: no menses since delivery
st
 1 question: Are you still breastfeeding? Because lactation
is a physiologic cause of amenorrhea
 IF: No, only breast fed a month & it has been a year since
st
she delivered, the 1 thing to rule out is PREGNANCY
 IF pregnancy has been ruled out, take note in the history
that from the last pregnancy, she had POST PARTUM
HEMORRHAGE
 DX: Sheehan’s syndrome 2 to Pituitary Necrosis
 Symptoms: It is not only a decrease in the gonadotropic
hormones, anything that comes out from the anterior
pituitary gland will be decreased so the patient becomes
HYPOTHYROID (↓FSH, LH, TSH, growth hormone etc.)
Among tumors the most common:
 PITUITARY ADENOMAS (MICRO or MACRO)
 PE: Signs of GALACTORRHEA
Remember prolactin is responsible for lactation, so in the
presence of microadenoma, patient will complaints signs
of hyperprolactinemia.
Hyperprolactinemia
 Causes secondary amenorrhea because prolactin is anti-
gonadotropin so it will depress the gonadotrophic
hormones. So if there is no FSH & LH, there is nothing to
stimulate ovaries to develop follicles to produce estrogen
and progesterone.
st rd
Case 07
The patient was prescribed MPA due to the CC of
irregular menses in which she bled having regular menses but
nd
for the 2 time in which she took, there is no bleeding.
st
1 Time - Significance of bleeding after taking progesterone:
 Patient is NOT pregnant
 She bled because it will be presumed that she has
estrogen primed endometrium because PG will not act if
the endometrium is NOT primed by estrogen
 Remember in the regular cycle, this is E effect giving rise
to a proliferative then she ovulates becoming secretory
phase
 Because if she is pregnant, progesterone will act as an
additional support for the pregnancy (Remember what
comes out from the placenta is PG)
nd
2 Time:-Significance of absence of bleeding:
 R/o pregnancy (Case: intact hymen, normal Pelvic Exam)
 If pregnancy: Note the time she is not bleeding (16 weeks)
so the rectal exam should have a palpable enlarged uterus
Non-response to MPA
 Also called: "Progesterone Challenged Test"
Problem: HYPOTHALAMIC due to
 Stress, too much exercise, becoming too obese or too thin
(anorexia nervosa)
 Tumors particularly CRANIOPHARYNGOMAS

So in History:
 No menses for several months & in reproductive age
group
Rule out pregnancy
Anything in the uterus
Discharge from the nipples (not milk)
Galactorrhea + Amenorrhea = Hyperprolactenemic

DX Test: PRL ASSAY

Most common cause: Pituitary Adenomas

 Do CT/ MRI to demonstrate the presence of the tumor &
differentiate from Micro & Macro

SX: Amenorrhea & Galactorrhea

 + Headache, blurring of vision - tumor is relatively big so
do CT & MRI
 Test for visual acuity/ perimetry (make you focus on 1
point then press something every time you see something
from the periphery)

PITUITARY MICROADENOMA
 TX: Dopamine Receptor Agonist: BROMOCRIPTINE
 End effect: ↓ PRL

PITUITARY MACROADENOMA
 TX: Transphenoidal Resection Surgery, NOT Craniotomy