Mechanism of hyperprolactinemia

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1 Hyperprolactinemia

2 Mechanism of hyperprolactinemia

3

4 Causes of hyperprolactinemia Hormone-producing pituitary tumors Prolactinoma Acromegaly Hypothalamic/pituitary stalk lesion Tumors, cysts (craniopharyngeoma, meningeoma, etc.) Empty sella Infiltratíve és inflammatory diseases Radiation therapy Trauma Pituitary stalk lesion Surgery Ectopic prolactin-producing tumors (carcinoma) Other endocrine and systhemic disorders Primary hypothyroidism Polycystic ovary syndrome Liver cirrhosis Renal failure

5 Structure of growth hormone and prolactin

6 Medications that may cause hyperprolactinemia

7 Plasma prolactin values in physiologic and pathologic conditions Physiological conditions ng/ml Baseline (morning) Men: 5-15 Women: 5-10 During sleep 50 Pregnancy 300 Pathological conditions Microprolactinoma 250 Macroprolactinoma 250 (usually 1000) Compression of pituitary stalk 150 Drugs 100 Primary hypothyroidism 100

8 Does this young girl have hyperprolactinemia? If yes, why?

9 Methodological problems Hook-effect Cause: very high prolactin concentration interferes with the 2nd antibody Macroprolactin Cause: Prolactin binds to IgG antibodies in plasma

10 Prolactin-producing pituitary microadenoma Young women (rarely in men) Clinical symptoms: Galactorrhea-amenorrhea Oligomenorrhea Infertility Osteopenia Hirsutism (mild) Decreased libido Breast atrophy (rarely)

11 Prolactin-producing pituitary macroadenoma Older age (same prevalence in men and women Late diagnosis in men Clinical symptoms Symptoms of hyperprolactinemia Women: Galactorrhea, disturbances in menstrual bleeding, hypogonadism Meni: hypogonadism, impotence, decreased body hair, gynecomastia Compression of surrounding structures Headache Bitemporal hemianopsia Paresis of external ocular muscles Nasal liquorrhea Obstructive hydrocephalus Hypopituitarism

12 Anatomy of sellar region

13 Development of hypopituitarism in progressive pituitary disorders

14 Medical treatment of prolactin-producing pituitary adenomas Bromocriptine (2.5 mg tabl. 5, 10 mg caps) mean daily dose: mg duration of action: 24 h side effects: gastrointestinal smptoms, hypotonia, Raynaudsyndrome, constipation, headache, psychosis Quinagolide (0.075, mg tabl.) mean daily dose: mg duration of action: 24 h side effects: see bromocriptine, but less frequent Cabergolin (0.5 mg tabl) mean daily dose: mg duration of action: 7 days side effects: very rare

15 Bromocriptine treatment in prolactin-producing pituitary macroadenoma and microadenoma

16 Effectiveness of bromocriptin treatment in prolactin-producing pituitary microadenoma

17 Effectiveness of bromoctiptine treatzment in prolactin-producing pituitary macroadenoma

18 Bromocriptine treatment in prolactinproducing pituitary macroadenoma

19 Bromocriptine treatment in prolactin-producing pituitary macroadenoma Before treatment (plasma prolactin: 2800 ng/ml) After 6 mo. (plasma prolactin 24 ng/ml)

20 Intratumoral hemorrhage in prolactin-producing pituitary macroadenoma treated with bromocriptine After 9 mo (plasma prolactin: 28 ng/ml) After pituitary surgery (plasma prolactin 1020 ng/ml)

21 Galactorrhoea-amenorrhoea szindróma (postpartum) 28-year-old woman 2 years after pregnancy galactorrhea, absence of menstrual bleeding Headache, weakness Gynecological exam: normal (except galactorrhea Prolactin, LH, FSH, estradiol Pituitary MRI scan

22 Galactorrhoea-amenorrhoea szindróma (postpartum) Hormonal findings Prolactin: 64 ng/ml (normal: 15 ng/ml) LH: 2 IU/l FSH: 1.4 IU/l Estradiol: 30 pg/ml Pituitary MRI Macroadenoma

23 Galactorrhoea-amenorrhoea szindróma (postpartum) Ophthalmology: Fields: Bilateral upper temporal defect Diagnózis: Prolactin-producing pituitary macroadenoma with compression of the optic chiasm Recommended therapy: Neurosurgery or medical treatment with bromocriptine

24 Galactorrhoea-amenorrhoea syndrome (postpartum) Hormonal findings Plasma TSH: 150 IU/l (normal: IU/l) free T4: 0.2 ng/dl (norm: ng/dl) free T3: 0.4 pg/ml (norm: pg/ml) Diagnosis Primary hypothyroidism

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