What is the management for a patient with galactorrhea, fatigue, menorrhagia, elevated Thyroid-Stimulating Hormone (TSH), normal Thyroxine (T4), and mildly elevated Prolactin level?

Management: Levothyroxine First, Then Reassess

The correct management is levothyroxine (option 2) to treat the primary hypothyroidism, which is the underlying cause of both the galactorrhea and menorrhagia in this patient. 1, 2, 3

Why Levothyroxine is the Answer

Primary hypothyroidism is causing the hyperprolactinemia and galactorrhea in this case. The elevated TSH with normal T4 indicates subclinical hypothyroidism, but the presence of galactorrhea and menorrhagia suggests this is clinically significant. 2, 3, 4

• Primary hypothyroidism causes hyperprolactinemia through increased TRH (thyrotropin-releasing hormone), which stimulates both TSH and prolactin secretion. 2, 3
• The prolactin level of 800 (just below the upper limit of 870) is consistent with hypothyroidism-induced hyperprolactinemia, which typically produces modest elevations rarely exceeding 100 ng/mL (though higher values have been reported). 2
• Treatment with levothyroxine normalizes TSH, which subsequently normalizes prolactin levels and resolves galactorrhea. 3, 4

Treatment Algorithm

Start levothyroxine at 1.6 mcg/kg/day for patients under 70 years without cardiac disease. 1

• Monitor TSH and free T4 every 6-8 weeks during dose titration. 1
• Target TSH within the reference range of 0.5-4.5 mIU/L. 1, 5
• Expect galactorrhea to resolve as TSH normalizes and prolactin levels decrease. 3, 4

Why Not the Other Options

Cabergoline (option 1) is incorrect because the hyperprolactinemia is secondary to hypothyroidism, not a primary prolactin disorder. 2, 3

• Treating the underlying hypothyroidism will normalize prolactin without dopamine agonist therapy. 3, 4
• Using cabergoline would be unnecessary and expose the patient to medication side effects. 2

Pituitary MRI (option 3) is not the initial step because this clinical presentation is classic for hypothyroidism-induced pituitary changes. 2, 3

• Primary hypothyroidism can cause pituitary hyperplasia that mimics adenomas on imaging. 3
• MRI should only be considered if symptoms persist after thyroid hormone normalization or if prolactin levels are disproportionately elevated (>100 ng/mL suggests investigating additional etiologies). 2
• The prolactin level of 800 in a range where normal is <870 is not sufficiently elevated to warrant immediate imaging. 2

Observation (option 4) is inappropriate because the patient is symptomatic with galactorrhea and menorrhagia. 1, 6

• Even with TSH in the subclinical range, symptomatic patients warrant treatment. 1, 6
• The presence of galactorrhea indicates the hypothyroidism is causing clinical manifestations requiring intervention. 4

Critical Pitfalls to Avoid

• Never assume hyperprolactinemia requires dopamine agonist therapy without first checking thyroid function. Primary hypothyroidism is a reversible cause of hyperprolactinemia. 2, 3
• Do not order pituitary MRI before treating obvious hypothyroidism. Pituitary hyperplasia from hypothyroidism can mimic macroadenomas and will regress with levothyroxine treatment. 3
• Avoid delaying treatment in symptomatic patients. The presence of galactorrhea and menorrhagia indicates clinically significant disease requiring immediate intervention. 1, 4

Expected Outcome

• TSH normalization typically occurs within 6-8 weeks of appropriate levothyroxine dosing. 1
• Prolactin levels decrease and galactorrhea resolves as thyroid function normalizes. 3, 4
• Menorrhagia should improve with correction of hypothyroidism. 1
• If symptoms persist after achieving euthyroid state, then consider alternative diagnoses and potentially pituitary imaging. 2