The primary objective is to treat the underlying cause.

Hormone replacement therapy should be considered to avoid prolonged oestrogen deficiency (Q6.20) if you have premature menopause(Q6.17). If you are not sexually active HRT (Chapter 28) would provide adequate oestrogen.

If you are sexually active and you wish to avoid pregnancy, the combined oral contraceptive pill would have two-fold benefit.

When there is associated infertility, every effort should be made to correct the underlying disorder before addressing fertility issues. Amenorrhoea suggests anovulatory infertility (Q9.17).

Prolonged weight-related amenorrhoea will be associated with the risks of oestrogen deficiency (Chapter 26) and hormone replacement therapy or a combined oral contraceptive pill should be considered. The primary objective is to encourage a more nutritious diet.

The management of Amenorrhoea and Oligomenorrhoea (Absent and infrequent Periods). associated with polycystic ovary syndrome is discussed in (Q7.13).

Hyperprolactinaemia (even in the presence of a tumour) will usually respond to medication with bromocriptine (Parlodel - Novartis). This drug may cause nausea and vomiting. It is best taken after meals and it is customary to build up the dose over a few days. If tablets cannot be tolerated by mouth, the tablets can be introduced into the vagina, where the drug is well absorbed with fewer side effects. Newer drugs, notably cabergoline (Dostinex Pharmacia and Upjohn), are becoming available but they are relatively expensive. When treatment is aimed at restoring fertility, it is generally recommended that the medication is discontinued when pregnancy occurs.

In 1995 I was invited to see a 26 year old lady who had a milky discharge from her breasts for 18 months. Occasionally she had headaches but no visual disturbance. She had no menstrual disturbance and she had not taken the combined oral contraceptive pill. Investigations showed normal thyroid function and no evidence of pituitary enlargement. Her prolactin was slightly elevated at 761 mU/l (normal range 150-450). She was commenced on Parlodel on an escalating regimen to 2.5 mg twice daily. She had mild nausea initially which settled. Her prolactin fell to 161mU/L and the galactorrhoea ceased. When the Parlodel was reduced to 2.5mg daily she had a little milky discharge and the twice daily regimen was recommenced; she was well on this regimen. In 1996 she was injured and seemed to develop post-traumatic disorder. She needed an antidepressant and her prolactin rose to 3400. A CT-scan of the pituitary suggested a micro-adenoma (a tiny innocent tumour) (there is a suggestion that up to 25% of the population may have such a problem). On Parlodel her prolactin remained in the normal range. However, she found the side effects a problem and decided to stop. There was no recurrence of the milk production and her periods continued regularly although her prolactin rose to 2007 u/L. It is difficult now to know whether the elevated prolactin is related to the anti-depressant or not. However, as she remains well, there is no pressing reason to treat the prolactin level. Our plan is to carry out regular MRI assessment of the pituitary to exclude the development of a tumour.

Women's Health



women's health



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