USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 29-year-old woman, gravida 2, para 2, comes to the office because of fatigue, failure to lactate, and amenorrhea for the past two months. She had delivered a healthy baby boy two months ago via spontaneous vaginal delivery, during which she required transfusion of two units of packed erythrocytes. She moved to the US from Turkey with her family one month ago. Since delivery, she has been unable to breastfeed her child and has yet to resume her menses. Physical examination shows sparse pubic hair. Which of the following factors is the most likely underlying cause behind her condition?
Content Reviewers:Rishi Desai, MD, MPH
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 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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