I admit it…sometimes I do watch “real life” medical shows on television. Last year I was watching “Medical Mysteries” on Discovery (I think) and the show presented a young woman who wanted to conceive but had not resumed menstruating after stopping oral contraceptives. She noted that her doctor prescribed “pills” to induce ovulation but when she failed to bleed the doctor ordered additional tests to evaluate if she could be in “early menopause.” Although not exactly correct the story seemed appropriate thus far. Then the doctor called her and gave her the good news that she was not menopausal. Great, I thought, so what did the MRI show?
The woman was then told to just keep trying and see what happened….not a great plan. A few months later she was in the movies and when she stood up she couldn’t see her feet! WARNING, WARNING, THIS IS A BAD SIGN! “So what did the MRI show!” I yelled at the TV (freaking out my wife, I must add who was quietly reading). The woman said that she thought that was weird but it wasn’t until she had a seizure 2-3 months later that her doctor was smart enough to order an MRI. “My doctor was so smart to think of doing that test,” she told the interviewer. Duh!
So the MRI showed a large benign brain tumor (meningioma). After it was removed her periods returned and she went on to have 2 kids….hooray. Happy ending but as you can read below the “smart” doctor was several months late in ordering that MRI! This whole mess could have ended up on the “Medical Malpractice Hour” if the patient hadn’t had such fondness for her doctor.
So here is today’s Question of the Day (which is not a daily feature…shame on DrG) from the book that was not on sale at the MIT Coop when I was in Boston last weekend, 100 Questions & Answers About Infertility.
26. If I don’t have either PCOS or POF, then what is my problem and why am I not ovulating?
Hormone abnormalities other than PCOS can also lead to irregular menstrual cycles. Such abnormalities include problems with the thyroid gland (which produces a hormone that controls metabolism), abnormal levels of prolactin (a hormone that induces breast milk production), and a lack of pituitary stimulation to the ovary known as functional hypothalamic amenorrhea (FHA).
The pituitary gland has been called the master gland of the body; it secretes hormones that control a wide range of functions, including reproduction, metabolism, response to stress, water balance, and growth. Women with irregular cycles should have their thyroid hormone and prolactin levels measured, because problems with the thyroid gland can indirectly lead to elevations in prolactin. Low levels of thyroid hormone (hypothyroidism) and elevations in prolactin (hyperprolactinemia) can be readily treated with medication. In fact, treatment of hypothyroidism with oral thyroid hormone (levothyroxine) can promptly restore normal menstruation. Similarly, hyperprolactinemia usually responds quickly to bromocriptine therapy, often promptly restoring normal cycles.
An elevation of prolactin in the absence of any thyroid disease requires magnetic resonance imaging (MRI) of the brain to evaluate its cause. In such cases, hyperprolactinemia usually results from an increased growth of the prolactin-secreting cells in the pituitary gland that forms a small tumor. If the prolactin-secreting tumor is less than 1 cm in diameter, then it is called a microadenoma. A macroadenoma is greater than 1 cm in diameter.
Women without thyroid or prolactin issues who fail to have menstrual periods following treatment with progesterone are usually referred to as having functional hypothalamic amenorrhea (FHA). These women fail to produce normal levels of estrogen despite an appropriate complement of ovarian follicles. Women who are below ideal body weight and who exercise frequently and vigorously are particularly prone to developing this problem. Women with FHA are at risk for osteoporosis and should discuss with their physician the benefits of hormone therapy (such as oral contraceptives) when not attempting pregnancy. They should also undergo an MRI of the brain to rule out any structural etiology for their condition. Women who are below ideal body weight may resume normal menstrual cycles when they gain weight or decrease their exercise frequency and duration.