Miscellaneous

Question 1

Briefly describe the hypothalamic axis in prolactin.

Answer 1

Prolactin is inhibited by dopamine, and TRH increases its secretion.

Therefore, hypothyroidism may increase TRH can causes hyperprolatinemia .

Question 2

What clinical signs would you like to examine the patient in hyperprolactinemia?

Answer 2

1. Bitemporal hemianopia (visual disturbance)
2. Galactorrea
3. Headache
4. Signs of hypothyroidism e.g. tibial myxoedema? (in Grave’s, Hashimoto thyroiditis), bradycardia, goiter, amenorrhea/ oligomenorrhea, constipation, weight gain, cold intolerance

Question 3

Further investigations for patient with prolactin level 2560 mIU/L? (4)

Answer 3

1. MRI brain for any pituitary adenoma
2. TFT
3. Hormone profile: LH, FSH, E2
4. Pregnancy test

Question 4

Management for hyperprolactinemia patients with pituitary adenoma?

Answer 4

1. Give bromocriptine
2. Review MRI
   - if microadenoma: continue treatment for 3 years

• if macroadenoma: refer to neurosurgery
• stop bromocriptine if no adenoma

Question 5

How to manage if patient is pregnant - when having bromocriptine for her microadenoma?

(Now and after preg)

Answer 5

• Stop bromocriptine.
• Restart bromocriptine if worsening S/S (headache, change in vision), visual field testing and MRI

Regular FU Q3M

• After pregnancy: stop bromocriptine because contraindicated in breastfeeding

Question 6

Miss Chan is a 32 years old woman. She has never been pregnant before. She works as a secretary in a legal
office. She is not in a steady relationship and uses condoms for contraception. Her periods were pretty
regular 18 months ago. However, during the last year, she has not had any periods. She has been
experiencing lack of sleep, loss of libido and mood swings.

What are the ddx in her case? (4)

Answer 6

1. Pregnancy!!!
2. Low FSH (=high estrogen)
   - Physiological: stress, exercise, weight loss
   - Endocrine: hypothyroid, cushing’s
   - Chronic illness: TB, malnutrition
   - Pituitary pathology: tumor, empty sella
3. Normal FSH
   - PCOS
4. High FSH
   - Premature menopause

Question 7

What are the investigations for amenorrhea in 32 years old women?

Answer 7

1. Urine pregnancy test
2. Hormone levels: FSH, LH, E2
3. TFT: TSH, T4
4. TVS for any ovarian cyst

Question 8

What are the levels of FSH that indicates menopause?

Answer 8

> 40, repeat after 3 months FSH still persistently >40 = menopause

Question 9

What are the effects of premature menopause?

Answer 9

1. Osteoporosis
2. CVS risk
3. Dementia risk
4. Peri-menopausal symptoms
   - hot flushes
   - mood disturbance/ vasomotor symptoms
   - sexual dysfunction due to vaginal atrophy
   - urinary frequency due to bladder atrophy

Question 10

How to manage a patient with premature menopause?

Answer 10

Management

• Hormonal replacement if needed
• Lifestyle modification: weight bearing exercise, vitamin D and calcium intake, increased sunlight exposure, avoid triggers for hot flushes: spicy food/wear thin clothes
• stop smoking and drinking caffeine

Question 11

How to counsel a patient with premature menopause?

Answer 11

1. Explain the condition
   - subfertility
   - no curative treatment
2. Implications of hypoestrogenism
   - Short term: vasomotor/ mood/ psychological

• Intermediate: urogenital/vaginal itchiness and dryness, increased frequency, increased chance of UTI
• Long term: osteoporosis, dementia, CVD

3. Infertility counselling
   - oocytes/ embryo donation
   - adoption
4. Investigate for underlying cause
   - genetic: Turner, Fragile X
   - Autoimune disease
   - Ovarian toxins: childhood chemo, pelvic radiotherapy
5. Offer psychological support