Thanks to Yolanda de Rijke for suggesting this case.

A 35 year old woman, seeing her Community Physician. No clinical
information was given on the request card. Results on a serum sample were

FSH:		55.0 IU/L	(follicular phase 2 - 11)
LH:		27.2 IU/L	(follicular phase 1 - 10)
Prolactin:	1420 mU/L	(80 - 530)
Testosterone:	1.2 nmol/L	(0.3 - 2.9)

Three years before, results on the same patient were
FSH:		61.6 IU/L
LH:		56.3 IU/L
Prolactin:	320 mU/L

This 'clearly impossible case' (thank you, Graham) attracted 37
participants.

4 would not comment until they had contacted the CP, [1.0]
16 would contact the CP to discuss the Case;[1.6]
3 would obtain a drugs history[0.5]
4 would obtain a menstrual history;[0.0]
2 would ask the CP to contact the lab;[0.0]
1 would ask the CP to 'provide clinical information, d**n it!' (thank you,
Aubrey).[-0.3]
1 would 'find out clinical history, then think it through' (thank you,
Steve).[1.2]

4 would measure oestradiol on this sample, [-0.2]
3 would measure TSH on this sample;[1.2]
1 would measure TSH and oestradiol on this sample.[0.4]
1 would measure HCG on this sample.[-0.6]

16 said (premature) ovarian failure likely; [1.0*]
2 queried surgically induced early menopause;[0.0*]
3 queried Turner's syndrome [0.1*]
2 queried ovarian resistance.[-0.6]
2 queried antibody interference with assays;[0.0*]
1 each queried 
	oestrogen replacement; [-0.6]
	hypothalamic-pituitary-gonadal axis lesion; [-0.4]
	lactating?;[-1.2]
	pregnant?[-1.4]
	infertile? [-0.2*]
1 said PCOS unlikely.[-0.2*]
	
Specifically about the increased prolactin
12 queried a drug effect; [1.2]
5 queried stress;[0.8]
4 queried primary hypothyroidism;[1.0]
3 queried macroprolactin.[0.8]

4 said a prolactinoma was unlikely; [-0.6]
2 queried prolactinoma; [0.8]
1 commented 'microprolactinoma'.[-0.8]

1 each suggested 
	a skull x-ray;[-0.3]
	referral for non-urgent endocrine advice; [1.4]
	referral to an endocrinologist for MRI scan.[-0.3]
5 suggested repeating the prolactin [1.5]
1 suggested repeating the prolactin on day 5 after 11am; [0.3*]
1 suggested repeating the prolactin at 6 - 12 month intervals.[-0.8]

Several participants have previously commented about the dangers of
over-interpretation, particularly when clinical information is minimal or
non-existent. I was delighted when Yolanda sent me this Case, because I
thought it would well illustrate the problem. However, it has also
illustrated considerable differences of opinion among the assessors!

Yolanda contacted the physician, and commented that she could not
understand the high levels of prolactin and gonadotropins in this lady. The
physician explained that he was treating this trans-sexual (man transferred
to woman) with Linoral to give gonadotropin stimulation, and also a
neuroleptic drug for depression. Yolanda comments 'If clinical information
is lacking with these cases, interpretation is difficult' - surely the
understatement of the year!

Some participants may think this Case is unfair, because in the Western
World tran-sexuals are rare. But by total coincidence I came across an
almost identical case here in Reading the week this Case was distributed -
fortunately in my case, the clinical information given was 'transexual (man
to woman); treated with oestradiol patches'. And I remember seeing some
very similar results last year which I could not understand. So I suspect
that the problem is not quite as rare as I thought it was.

Best wishes
Gordon Challand


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