When a doctor prescribes a drug with uncomfortable side effects.....

A 35 year old woman came to my clinic in the hospital because she had noticed discharge of milk from both her breasts. Her last pregnancy was more than 4 years ago. Her physical examination was normal. I wondered if she had hyperprolactinemia and I requested a test for the same.  I also asked her about her menstrual cycles and whether she experienced any hot flushes because I was aware that increased prolactin levels diminished secretion of estrogen from the ovaries. She said that her menstrual cycles were erratic. She did not have any hot flushes. I should have discussed about libido but I did not. Anyway, the serum prolactin levels were high in her and that made me suspect that she had a prolactin secreting tumour in the pituitary. I examined her cranial nerves, pupils, optic disc and visual acuity and field of vision. Nothing abnormal was detected.

The patient was worried when she realised that she might have a tumour in the brain. I explained to her that such tumours were never malignant and that, in most cases, it was so small that we did not even call it a tumour. Instead we called it a microadenoma. She wanted to know how small it was. I told her that a microadenoma is, by definition, something that is less than 10mm in diameter and I showed her how small it looked on paper.

An MRI was then done for her. It confirmed a microadenoma of the pituitary. I then tested her thyroid function and her serum cortisol level because, even though it was only a microadenoma, I wanted to make sure that it was not impinging on the function of the adjacent parts of the pituitary gland. These tests were normal.

In consultation with an endocrinologist she was then offered treatment with a dopamine agonist. We offered her bromocriptine because that was the only drug available with us in the hospital. I knew though that the best dopamine agonist for reducing serum prolactin was cabergoline. Dopamine agonists are also used to treat Parkinsonism and my patient had an uncomfortable moment when the pharmacist who dispensed her medication told her that she had Parkinsonism. It took me awhile to reassure her that she did not have that neurological disease.

When she began to suffer nausea and vomiting because of the bromocriptine, she consulted another doctor in a different hospital. Following the advice there, she underwent transsphenoidal resection of the microadenoma. This is a technique where the tumour is excised through an incision in the nose so that the lesion can be approached through the sphenoid sinus.

She came back to see me after the surgery, happy that she did not have to take the bromocriptine anymore. I learnt something useful from this encounter: when a doctor prescribes a drug that causes uncomfortable side effects, the patient blames the doctor, not the drug!