Galactorrhea with menstrual irregularity: something other than a prolactinoma?
A 29-year-old female with no premorbidities was admitted with complaints of galactorrhea for the past week and menstrual irregularities over the past six months. Her last childbirth six years ago had been uneventful. She denied any history of substance abuse. There was no significant family history. General physical examination showed mild pallor. Systemic examination was entirely normal. Routine laboratory investigations showed elevated serum prolactin (190 ng/mL). Liver enzymes were minimally elevated, while albumin-globulin ratio was reversed (serum albumin: 2.3 gr/ dL, serum globulin: 4.1 gr/dL). Renal and thyroid function tests were normal (serum urea: 34 mg/dL, serum creatinine: 1.4 mg/dL, TSH: 2.6 mIU/L). Prothrombin time was prolonged (patient: 20.9 sec, control: 14.8 sec; INR: 1.49). Abdominal ultrasound demonstrated coarse echotexture of the liver, a dilated portal vein (12 mm) and mild splenomegaly (12.3 cm), features consistent with hepatic cirrhosis. Although stool examination was negative for occult blood, upper gastrointestinal (GI) endoscopy revealed grade I esophageal varices and mild portal hypertensive gastropathy. MRI imaging of the brain was performed and ruled out the presence of any pituitary mass.\nAs the patient continued to have galactorrhea, gynecological consultation was sought. Transvaginal ultrasonography was unremarkable; serum levels of gonadotrophins were normal (serum FSH: 11.82 mIU/mL, serum LH: 2.51 mIU/mL) and expectant management was advised.\nThe patient was now evaluated for the cause of cirrhosis. Serologic markers for hepatitis B and C infections were negative, as were tests for anti-nuclear antibodies. However, serum ceruloplasmin was low (9.0 mg/dL); 24-hour urine copper estimation was significantly elevated (758 mcg). Slit lamp microscopy revealed Kayser-Fleischer rings () and sunflower cataracts (). A diagnosis of compensated hepatic cirrhosis secondary to Wilson’s disease with symptomatic hyperprolactinemia was made. Retrospectively, the patient displayed no evidence of neurological involvement, either clinical or radiological, despite the presence of Kayser-Fleischer rings. Therapy with d-penicillamine was initiated at 300 mg TID, and subsequently increased to 600 mg TID. On follow-up she reported significant improvement in symptoms including cessation of galactorrhea within 3 months and regularization of her menstrual cycle.