Case History/Examination:
A 24-year-old female with no comorbidities presented with complaints of
Galactorrhea and menstrual irregularities for 1.5 years. She had been
using norethisterone for her menstrual issues. She reported a weight
gain of 20 kilograms over the past 18 months, accompanied by polyuria,
mild headache, myalgia, and numbness in her upper limbs. She had a
history of delivering a child via C-section 3 years ago but had no other
notable past medical or surgical history. Physical examination was
unremarkable.
Her complete pituitary profile was checked, which showed high TSH and
low Free T4. Her lab results are shown in the table below (Table
1).
These labs were significant for hypothyroidism, so there was a suspicion
of pituitary hyperplasia with hypothyroidism, but prolactin levels were
also high, so the possibility of pituitary macroadenoma could not be
ruled out completely
An MRI of the brain was done a few days before her presentation in the
clinic. It showed an enhancing mass in the sellar and suprasellar
locations, measuring 11x 16 x 14 mm (AP x TR x CC). An associated mass
effect causing downsloping of the sellar floor into the sphenoid sinus
was noted. The mass was also compressing the pituitary stalk. Findings
were suggestive of pituitary macroadenoma. Images of the MRI brain are
shown below in Figures 1 and 2.
As per the multidisciplinary team meeting, it was planned to start her
on levothyroxine 100mcg daily and assess the response in an interval MRI
brain in 2 to 3 months. Hence, she was advised levothyroxine, which she
took regularly with good compliance.
MRI of the brain repeated after 2 months showed interval resolution of
the enlarged pituitary gland. It measures 5.7 x 9x 12 mm (CC x AP x
Transverse) against the previous 14 x 10 x 17mm measurements. It showed
a good treatment response to levothyroxine. Radiological images of the
MRI brain are shown below. The arrow shows the complete resolution of
the mass shown before (Figures 3 and 4).
After starting levothyroxine, the patient’s symptoms resolved
significantly. Her menstrual cycle normalized, and she became pregnant
with her second child. The pregnancy was uneventful, resulting in the
delivery of a healthy baby. Her issues with galactorrhea and body pain
also resolved. She was advised to return for a follow-up MRI in four
months; however, she missed this appointment due to her pregnancy. Lab
results showed marked improvement after two months, especially in her
TSH levels (Table 2).