USMLE® Step 1 style questions USMLE
A 34-year-old woman, gravida 1 para 1, comes to the clinic due to an inability to breastfeed her baby. She had a spontaneous vaginal delivery of a healthy newborn at full-term 3 weeks ago. The labor was complicated by postpartum hemorrhage secondary to retained products of conception, and she required transfusion with 3 units of packed red blood cells. She has been using formula for feeding, as her milk never “came in.” Review of systems is significant for increased fatigue over the same period, which she attributes to lack of sleep. Temperature is 36.5°C (97°7 F), pulse is 102/min, and blood pressure is 92/76 mm Hg. Physical examination reveals cool, dry skin. Which of the following is the most likely cause of this patient’s condition?
Hypoprolactinemia exam links
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS, Evan Debevec-McKenney, Jahnavi Narayanan, MBBS, Brittany Norton, MFA
With hypoprolactinemia, hypo- means below, -prolactin refers to the hormone produced by the pituitary gland, and -emia refers to the blood, so hypoprolactinemia means lower than normal prolactin levels in the blood.
Normally, at the base of the brain, there’s a small pea-sized gland called the pituitary gland.
The anterior pituitary - which is the front of the pituitary gland - has a number of different cells, each of which secrete a different hormone.
One group, the lactotroph cells, secrete prolactin.
In men, prolactin decreases testosterone production.
In women, during pregnancy, elevated levels of estrogen stimulate the lactotroph cells to produce large amounts of prolactin which stimulates alveolar cells in the breasts.
In response to prolactin, the alveolar cells divide and enlarge - and once a baby is born, lactogenesis starts - which means that milk is produced.
Apart from milk production, high levels of prolactin also inhibit the release of gonadotropin releasing hormone from the hypothalamus, which results in decreased luteinizing and follicle stimulating hormone levels, which in turn, decreases estrogen levels.
In women, this can stop ovulation and menstruation, which is why women typically don’t have a menstrual period while breastfeeding.
In women that are not pregnant or breastfeeding, as well as in men, prolactin levels are usually kept in check by the hypothalamus in two ways.
The first way is the most important, and it’s when the hypothalamus secretes a constant stream of dopamine which in this setting is called prolactin inhibiting factor.
Dopamine binds to specific receptors on the lactotroph cells and inhibit the release of prolactin.
The second way is less significant, and it’s when the hypothalamus secretes thyrotropin releasing hormone, also called prolactin releasing hormone, which can stimulate prolactin release.
If the level of prolactin rises for any reason, then it signals the hypothalamus to release more dopamine, eventually decreasing its own production, a process called negative feedback or feedback inhibition.
The most common cause of hypoprolactinemia is Sheehan’s syndrome, a disorder where lactotroph cells die in a woman that has recently given birth and has postpartum hemorrhage - excessive blood loss during delivery.
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