Instructions
You are a medical student on placement in general practice. Your next patient is Chiara Mancuso, 31, from Geraldton, who has had no periods since her second baby was born nine months ago. She is back for her test results, which are below.
Explain the results and your management plan to the patient
- You do not need to take a further history or examine the patient.
From her visit last week
Heavy bleeding after the birth: six units of blood and three days in intensive care. Her milk never came in; the baby is formula-fed. Tired, cold, low sex drive, weight gain, light-headed on standing. Breastfed her first child, now 4, for a year.
Blood tests, 9 am last week
hCG under 5 IU/L (normal). Oestradiol 55 pmol/L (low). LH 0.6 IU/L (low). FSH 0.9 IU/L (low). Prolactin 40 mIU/L (low). TSH 1.2 mIU/L (normal). Free T4 7 pmol/L (low). Cortisol 70 nmol/L (low). IGF-1 8 nmol/L (low). Sodium 131 mmol/L (low). Potassium 4.2 mmol/L (normal). Glucose 4.1 mmol/L (normal).
MRI pituitary with contrast, last week
Pituitary fossa filled largely with fluid; the gland is a thin rim of tissue flattened against the floor of the fossa. Stalk central. No mass or bleeding. Optic chiasm normal. Conclusion: empty sella.
Blood tests (taken at 9 am last week)
| Item | Value | Reference range |
|---|---|---|
| Serum hCG | Less than 5 IU/L | <5 IU/L |
| Oestradiol | 55 pmol/L | 100-900 pmol/L |
| LH | 0.6 IU/L | 2-12 IU/L |
| FSH | 0.9 IU/L | 3-10 IU/L |
| Prolactin | 40 mIU/L | 100-500 mIU/L |
| TSH | 1.2 mIU/L | 0.4-4.0 mIU/L |
| Free T4 | 7 pmol/L | 10-20 pmol/L |
| Cortisol, 9 am | 70 nmol/L | 140-600 nmol/L |
| IGF-1 | 8 nmol/L | 14-40 nmol/L |
| Sodium | 131 mmol/L | 135-145 mmol/L |
| Potassium | 4.2 mmol/L | 3.5-5.2 mmol/L |
| Glucose, fasting | 4.1 mmol/L | 3.0-6.0 mmol/L |
Reference ranges for LH, FSH and oestradiol are for the follicular phase of a regular cycle.
MRI pituitary with contrast (last week)
The pituitary fossa is normal in size and filled largely with fluid. The gland is a thin rim of tissue flattened against the floor of the fossa. The stalk is central. No mass or bleeding. The optic chiasm is normal. Conclusion: empty sella.