False pregnancy?

[bryonyvaughn]

I'm concerned about a friend and would like your input on this case.

46yo female, been in peri-menopause for the the last several years. 4' 9.5" and 85 lbs normally. Over the past 6 weeks her breasts have increased two cup sizes, belly has expanded, gained 5lbs, and began leaking colostrum over the last week. She's also started feeling her pulse in several areas of her body like happens with the increased blood volume of pregnancy as well as strange movements on the left side of her abdomen. Several urine tests have come back negative, and per my request took a beta HCG. She estimates if she were pregnant she'd be entering her 4th month.

This afternoon I palpated her abdomen and could not feel her uterus. I did feel a mass about 3" wide by 1.5" high halfway between her naval and solar plexus. She ate lunch about 1hr before I felt her abdomen and had a smoothie for breakfast that morning. She's been vegan (except for honey) for the past 12 years and a raw vegan the past year or so.

Even though she's so tiny she drinks about 1.5 gallons of water a day to prevent dehydration. I suspected diabetes insipidus but she assured me if she cuts back her water intake, he urine output decreases while she gets dehydrated within about 12 hours. Since today's negative beta hcg results and my not being able to palpate her uterus, I'm concerned about pituitary issues causing dilute urine/dehydration as well as false symptoms of pregnancy.

Has anyone heard of pituitary issues causing symptoms of pregnancy? Any other thoughts on what might be going on?

I made a referral on to a HCP very knowledgeable in hormonal feedback systems but am concerned about her as a friend and wanted some ideas before the two months it takes for her to see a specialist.

~BV

[bryonyvaughn]

If you want to throw out an "My professor once told me about a midwife who had a case where..." or "I once saw an episode of House where..." type comment I'd be glad to hear it.

~BV

[pamamidwife]

Wow, I'd be interested to hear what anyone thinks. This is interesting.

[mwherbs]

could be any of the hormone systems, thyroid, pit , direct stimulation and ovarian - including PCOS not all women with PCOS are heavy- with the way she is eating may be keeping her weight off and would fit into the diabetes/blood sugar sense you are getting-- even the mass could be related to this-

with that being said she chooses very restrictive diets and finds use and relief of symptoms from that the same may be true of her choice in hydration- maybe she is drinking that much for health reasons- and she notices changes and it may be a simple "health" choice. I am courious about the location of the mass and is it her intestines or something else ... also women during perimenopause and menopause will put on some tummy weight--

you could do some labs- including a glucose test...

[bryonyvaughn]

Actually her sugar levels are very consistant and she doesn't have a single sign of PCOS. I was thinking pituitary issues because of suspected diabetes insipidus (water diabetes) not diabetes mellitus (sugar diabetes.)

She's been vegetarian for 30 years and vegan for the 12 years of her marriage to a vegan man. The honey exception is due to his knowledge of the normal winter die-off bees in this northern climate. They'd say their diet is for philosophical and moral reasons, not nutritional or weight control reasons. She adopted raw veganism as an attempt to imitate the diets of other primates in pursuit of "natural" health.

One thing she has noticed is an increased energy on the raw diet. Many folks experience this when they first switch but end up with decreased energy long term as they aren't getting enough fats and proteins. This woman hasn't run into that problem with her particular dietary mix. I think part of it is she does it smarter than most raw vegans and part of this is she made the common mistake of vegans previously by overly depending on starches like breads and pastas as a quick and easy filler. During her last pregnancy (7 years ago) she gained LOTS of weight. She became a "starchitarian" pigging out on breads, pasta, and potatoes.

My point is her current diet is philosophically driven, not an attempt to feel better or control her weight. She exercises daily and is build like a brick $h!+ house... albeit is a small brick $h!+ house.

So far as tummy weight goes, up until a month or two ago her stomach was the flattest it's ever been in her life. Her abs are like how a male comic book character's would be drawn. She's really ripped. Her breasts started swelling larger and larger (which is especially significant with her low % body fat) over the last two months and her stomach has swollen (IMO so little that only she and perhaps her husband would ever notice) in the last few weeks. I think most of the five pounds is in her breasts.

So far as the mass I felt...
I was trying for a fundal height and couldn't find a uterus at all. I assume it is still tucked safely behind her pubic bone.

You know how you find fundal height by doing a sort of gentle karate chop type of move up an abdomen? Because of odd sensations (movements?) up the left side of her abdomen, I was doing those karate choppies all the way up her abdomen. About 2/3 the way up from her navel to her xyphoid (sp?) processl, I hit a ledge. It felt like what you'd imagine if her cervix were at her heart and her fundus was growing toward her navel. I asked her if she felt that and she said no. I described it to her and she commented she'd been working out her upper abs a lot lately. She did a mini crunch and her entire abdomen turned into an *eight* pack. It clearly wasn't a muscle I'd felt. Once she relaxed again I was able to push the sides of the lump toward each other so instead of being a ledge like before, it was a large pill shape about 3" wide and maybe 2" high. It seemed flatter on the bottom and rounder on the top (if she been standing up instead of lying down.) Then again I was bumping up against it's bottom long before I started feeling the sides and top.

I can't imagine a hernia being so big and then squishing smaller. It makes me suspect it might have been her breakfast in a convenient to palpate spot in her small intestine and I just kind of squished it into a a tighter bolus. Because of this I'd planned to palpate her upper abdomen 1 1/2 hours later before we left BUT we both got distracted with kids and getting home for dinner and forgot.

So far as tests, we're having her PCP order them in two weeks so her insurance will cover them. A first morning urine dip stick showed normal pH and specific gravity so, despite her enormous water consumption, her urine wasn't dilute! It also showed no sugar in the urine but those dips stick sugar tests are so crude I don't rely on them. Brix showed no sugar in urine.

I'd like for the PCP to order a blood draw panel showing the typical female pregnancy and nursing hormones as well as testosterone. The testosterone is a long shot but I've read that testosterone is sometimes used to dissolve a persistant corpeus luteum in dogs which will cause pseudocyesis. *Sometimes* a persistent corpeus luteum is found in humans with pseudocyesis. If all the bloodwork comes back normal except for low testosterone, I figure it might justify an ovarian U/S. I'm just a little nervous the pituitary is more likely. She certainly doesn't fit the social or emotional profile of someone with pseudocyesis.

Any other testing suggestions (as well as the *why* behind them) would be appreciated.

~BV

P.S. I'm passing this case on as out of my league but am curious about it as a learning experience as well and hoping for the best for a friend.

Originally Posted by mwherbs

could be any of the hormone systems, thyroid, pit , direct stimulation and ovarian - including PCOS not all women with PCOS are heavy- with the way she is eating may be keeping her weight off and would fit into the diabetes/blood sugar sense you are getting-- even the mass could be related to this-

with that being said she chooses very restrictive diets and finds use and relief of symptoms from that the same may be true of her choice in hydration- maybe she is drinking that much for health reasons- and she notices changes and it may be a simple "health" choice. I am courious about the location of the mass and is it her intestines or something else ... also women during perimenopause and menopause will put on some tummy weight--

you could do some labs- including a glucose test...

[mwherbs]

so PCOS is complex and I thought that it could still be a finding in thin women and that sugars could be maintained- through diet and exercise -- but the studies I have read point to liver problems in the thin PCOS women and the liver does hormone management-- one consideration.
While looking for the supportive info I just wrote-I came across this new abstract--------

Ann Endocrinol (Paris). 2007 Jun 13; [Epub ahead of print]

[Etiological diagnosis of hyperprolactinemia.]

[Article in French]
Cortet-Rudelli C, Sapin R, Bonneville JF, Brue T.

Clinique Linquette, 6, rue du Professeur-Laguesse, 59037 Lille cedex, France.

There are numerous etiologies of hyperprolactinemia, a common reason for
consultation. Diagnostic measures must be capable of identifying the tumors, the most frequent of which are prolactin adenomas. Hypothalamic-pituitary MRI is the reference morphological examination. In clinical practice, it is usually performed very early, following the discovery of increased plasma concentrations of PRL. This approach is warranted for marked increase in PRL in the absence of drugs with hyperprolactinemic effects (>10 x upper limit of normal) since a diagnosis of PRL adenoma is extremely likely under such circumstances. When hyperprolactinemia is moderate, which is the most common finding in practice, all etiologies are possible in theory and it is important to follow a rational diagnostic plan (history-taking to identify use of any drugs with hyperprolactinemic effects paying attention to renal and hepatic history, investigation for endocrine diseases occasionally associated with hyperprolactinemia such as hypothyroidism or polycystic ovary syndrome (PCOS), confirmation of hyperprolactinemia by a second assay when the initial level is less than 5 times the upper normal limit, pregnancy testing for women of childbearing age) in order to rule out all non-tumoral causes of hyperprolactinemia before proceeding with imaging. Absence of any consequences of hyperprolactinemia on gonadic function or the existence of a concomitant disease that could account for the clinical signs, demonstration of wide variations in PRL from one assay to another in a single patient could prompt screening for macroprolactinemia before MRI is ordered. Macroprolactinoma could also occur in the case of normal or doubtful MRI or discrepancy in response to medical or surgical treatment. T1- and T2-weighted coronal sections (with or without T1 after gadolinium injection) are generally sufficient for diagnosis of microprolactinoma. Dynamic tests may be useful if MRI is normal or unclear. Gadolinium injection with sagittal and axial sections is essential for examination of large lesions. In this case, when the increase of PRL is moderate (<150 mg/ml), a non-lactotropic lesion may be suspected without misdiagnosing a hook effect. Careful analysis of the images allows differentiation between
tumoral lesions and pituitary hyperplasia.

PMID: 17573032 [PubMed - as supplied by publisher]

-----------------------------
so there is that info-- and then on diabetes insipidus- pituitary failure ----

Pituitary. 2007 Jun 27; [Epub ahead of print]

Pituitary abscess: our experience with a case and a review of the literature.

Dalan R, Leow MK.

Department of Endocrinology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng,
Singapore, 308433, Singapore, [e-mail].

Pituitary abscess is a rare disease. Due to its potentially high mortality and
morbidity rate, it should be considered in the differential diagnosis of sellar
masses. Despite recent advances in radiological investigations, making a
definitive diagnosis preoperatively remains challenging. This 45-year-old Indian gentleman presented with severe throbbing headache for six months. Magnetic resonance imaging of the brain revealed a sellar mass with peripheral enhancement that was misdiagnosed as a pituitary macroadenoma. A trans-sphenoidal excision was done, which surprisingly yielded only pus that was drained accordingly from the lesion. Fungal and bacterial cultures were negative. However this patient subsequently lost complete function of the pituitary gland, resulting in central diabetes insipidus and required permanent hormonal replacement therapy in the deficient endocrine axes. A Medline search was conducted and a review of 24 cases
reported in the last 5 years discussed.

PMID: 17594523 [PubMed - as supplied by publisher]

[zofranland]

what about a prolactin level... hyperprolactinemia is where the prolactin levels are high as they are during pregnancy. it is either a malfunction of the pituitary or a tumor affecting he pituitary (usually benign)... they cause increased breast size, lactatation and menstrual irregularities if the menses occurs at all! there are multiple sites that address this issue!

http://en.wikipedia.org/wiki/Hyperprolactinaemia

[mwherbs]

yea I sent the abstract along but not necessairly to point to that particular illness just how pitutary tumors can do a collection of things--

my sister is on anti-psychotic meds and she always has elevated prolactin levels- ( unless she stops taking them)I was told that what they look for is a prolactin level that is very very high like 5000 and that that would be a tumor since she has only levels in the 100's it isn't a tumor just the drugs--

[dewi]

Have you ruled out uterine cancer?

Sounds like the symptoms my friend had before being diagnosed with stage 4 cancer.

[bryonyvaughn]

Originally Posted by dewi

Have you ruled out uterine cancer?

Sounds like the symptoms my friend had before being diagnosed with stage 4 cancer.

Oh, dear. No I haven't.

We've talked and think the abdominal stuff is related to her diet healing her body clearing out literal crap that's been in there for 20-30 years when she had lots of serious G/I issues.

She ended up going to a walk in clinic and got the doctor to order blood draws for the various hormones we'd like to check out. Her PCP appointment is late next week and she has the consultation in 1 1/2 months (I think it is now.)

I'll definitely add it to the list of conditions that can cause her symptoms.

Thanks for the input.

~BV