QUESTION--Referred to me for elevated prolactin levels and being evaluated for infertility  reproductive endocrine. 25 y.o. WF is here as new pt for the management of elevated prolactin levels and pituitary macroadenoma. Pt Ob/gyn did her prolactin levels as a part of work up for infertility which were mildly elevated and that lead to the work up of MRI of the pituitary.MRI of pituitary - 08/11/2017 - Left intra and suprasellar mass, measuring overall about 11 x 13 x 9 mm, elevating the stalk and left cisternal optic nerve, somewhat multilobular but without convincing evidence of cavernous sinus invasion.  It displaces the pituitary stalk rightward.  Presumed pituitary adenoma.

Pt was diagnosed with endometriosis in Aug 2017 when she underwent laparoscopic cystectomy of both ovaries and saw scar tissue on the left ovary and pt reports that her left ovary is not functioning due to the scar tissue every where but the right ovary also has a cyst. Pt was also noted to have endometriosis every where.. Menarche at age 11, periods have been are relatively irregular , pt cramps a lot for the first two - 3 days.

Pt has always been obese, weight has been stable, no issues with facial hair. Reports occasional headaches, no blurry vision or double vision but pt has right eye blindness and is born that way, no discharge from breasts or breast enlargement, no temporal loss of vision. Pt is OCP's since Sep 2017 to help with endometriosis. Currently planning to conceive for about few months. No prior pregnancies.

Lab work up –10/20/2017 10:54

Ref. Range 5/31/2017 11:09 7/21/2017 08:51 7/27/2017 14:44 8/18/2017 09:49 10/13/2017 10:17
17-Hydroxyprogesterone Latest Units: ng/dL 181
ACTH Latest Ref Range: 7.2 - 63.3 pg/mL 33.1
DHEA-Sulfate Latest Ref Range: 110.0 - 431.7 ug/dL 306.4
Prolactin Latest Ref Range: 4.8 - 23.3 ng/mL 29.8 (H) 32.7 (H) 32.9 (H) 30.8 (H)
Progesterone Latest Units: ng/mL 0.2
Testosterone, Total Latest Ref Range: 8 - 48 ng/dL 42
Testosterone, Free Latest Ref Range: 0.0 - 4.2 pg/mL 3.1
Insulin Latest Ref Range: 2.6 - 24.9 uIU/mL 9.1
TSH Baseline Latest Ref Range: 0.270 - 4.200 mIU/mL 3.31 4.200
Free T4 Latest Ref Range: 0.93 - 1.70 ng/dL 1.15


10/20/2017 10:54

Ref. Range 10/13/2017 10:17 10/16/2017 16:57
ACTH Latest Ref Range: 7.2 - 63.3 pg/mL 33.1
Cortisol, 24H Ur Latest Ref Range: 0 - 50 ug/24 hr 112 (H)
Cortisol, Free Latest Ref Range: Undefined ug/L 28


Since she has been on oral contraceptive pills I performed her 24-hour urine cortisol levels but the levels are elevated and given the fact that she has a pituitary  macroadenoma within normal ACTH levels I am concerned as to what to do next ? Thanks a lot for your help.  Manikya.Kuriti, MD

RESPONSE--It seems your patient has a macroadenoma, very slightly elevated prolactin probably representing stalk effect and you have a ACTH in the normal range and elevated afternoon cortisol and 24h cortisol while on oral contraceptive.So you are raising the possibility of (1) a non-functioning pituitary adenoma and elevated cortisol due to high CBG due to the pill or (2) the possibility of Cushing’s diseases.

You did not describe any signs or symptoms of Cushing’s except obesity but you did not say it was central and accompanied by striae, think skin, muscle weakness, hirsutism, DHEAS in normal range. If indeed this is the case, then the cortisol values might be die the pill and you should ask her to stop and reassess without the pill, If you still think Cushing is a possibility doe a Dexamethasone test (overnight or low dose 2mg 48h one), also do a midnight salivary cortisol if you have that test available.

If Cushing is ruled out then she probably has a clinically non-functioning adenoma. This needs operation. Find an experienced pituitary specialist surgeon.  In case this is a silent (or whispering if you have mild corticol abnormality after stopping her pill) corticotroph watch carefully postop cortisol levels. Marta Korbonits MD, PhD