Hyper Prolactin Emi A

7/24/2019 Hyper Prolactin Emi A

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Hyperprolactinemi

aHIMA San Pablo



ObjectivesReview biological and physiological

characteristics of prolactin.

Identify mayor pathologies andpathophysiology of hormone dereglation

Analysis bene!cial treatment schedle andprognosis.



"ormal Pititary Anatomy

. "eroendocrinology of Pititary Hormone Reglation. $ndocrinology and Metabolism %linics &'()*+,+-& &/0*



"ormal Pititary Anatomy

ed from #echan RM. "eroendocrinology of Pititary Hormone Reglation. $ndocrinology and Metabolism %linics &'()*+,+-& &/0*



ProlactinHman prolactin is a &// amino acid

polypeptide.

%romosome '.1lood PR# ( Monomeric 2)34 4imeric

)034 Polymeric 5&--3d. 6RH stimlate7

Half life( 2+,+- min."octrnal elevation.8idney 9iltrated.



Prolactin

Secretion dopamine42,type receptors located on lactotrophs :a3;S6A6 molecles domain.$strogen indces #iver PR#,receptor

Receptor %hromosome +.<=#iver 1rest #iver Adrenal corte> 3idneys

Prostate Ovary 6estes Pancreatic islets 1rain#ymphocytes.





Functions of Prolactin $ssential Hman speciesPbertyMammary glands ( 4ctal morphogenesis 6erminal end bds development( branching to networ3

dcts. I?9,& estrogens.

Pregnancy PR# serm mean 2-*g;#t

Amniotic @ids 5 &-> higher?landlar development ( Secrtory prodcts alveolar

lmina. I?9,& estrogen Progesterone hP#. Bitch mil3C



Functions of Prolactin #actationSc3ling increased PR# levels 0>.

Mil3 prodction.#actation Amenorrhea4iminish ovlation and nmber primary follicles. Sppress 9SH #H levels Sppress 6estosterone levels sperm cont motility.

Immne#ymphocyte growth factor.



Sellar Masses

Pititary Adenoma #ymphocytic Hypophysitis





SIGNS AND SYMPTOMS OF PROLACTINOMAS

SIGNS AND SYMPTOMS ASSOCIATED WITH TUMOR MASS

Blurred vision or decreased visual acuity

Cranial nerve palsies

Headaches

Hydrocephalus (rare)

Pituitary apoplexy

Seizures (temporal lobe)

Symptoms of hypopituitarism

Unilateral exophthalmos (rare)

Visual field abnormalities

SIGNS AND SYMPTOMS ASSOCIATED WITH HYPERPROLACTINEMIA

menorrhea! oli"omenorrhea! primary amenorrhea! infertility

#ecreased libido! impotence! premature e$aculation! erectile dysfunction! oli"ospermia

%alactorrhea

&steoporosis



%linical $valationPhysical History.Pregnancy

HormonesProlactin 6SH 96)A%6H AM cortisol midnight salivary cortisol#H 9SH estradiol progesterone testosterone

Inslin,li3e growth factor,& GI?9,&#iver pro!le 3idney fnction



4iagnosis"ormal vales PR#Males( 2 to 18 ng/mL."onpregnant females( 2 to 2/ ng;m#.Pregnant women( 10 to 209 ng/mL.

P%OS( =-E have mild PR#.

Hypothyroid ( 2-E pts have elevated PR#.

$S84( PR# moderated elevated mean 20g;#.?9R

4RD?S.



4iagnosisIdiopathic prolactinemia(PR# levels mean )+ g;#.

Resistance dopamine."o %ase.

MacroprolactinemiaPolymeric form 5&--34

Se>al dysfnction galactorrea osteoporosis.Polyethylene glycol precipitation serm samplesMight represent 22E of Hyperprolactinemic

states.



bstet ?ynecol &/*2J &&=(&)J " $ngl : Med &/**J 2/'(+0/J %lin 6her 2--J 22(&-0+J %lin $ndocrinol &/*'J +(2*=Jndocrinol Metab &/*'J )2(&&)0J : %lin $ndocrinoll Metab )2( &0&J : %lin $ndocrinol Metab &/02J +)(0'/J 1r Med : &/*'J &(&&0'J/*'J 2=+(2=&'J Am : %ardiol &/0=J +&(&)''J : %lin $ndocrinol Metab &/0+J '-(&)).







Pharmacotherapy4opamine agonists( bromocriptinecabergoline, most sefl for prolactinomas lesssefl for ?H secreting adenomas

Somatostatin analog GOctreotideOctreotide #AR, most sefl for acromegaly

Pegvisomant G?H receptor bloc3er, sefl inacromegaly refractory to somatostatin analoges

Other( 3etoconaKole metyraponemitotane, for %shings disease, se limited byside eLects e>pense and lac3 of ecacy



4opamine Agonist

6herapy

Bebster : et al. " $ngl : Med &//)J ==&(/-).



#ong,term $Lects of 1romocriptine 6herapy

: %lin $ndocrinol Metab +-(&-2' &-==



Sccess Rate of 1romocriptine in

AmenorrheaAfter & month of

treatment one woman infor will retrn to normalmenstral cyclingJ

In 2 months this nmberwill increase to si> ot of&-

After &- months eightot of &- women will bemenstrating normally

Of the remaining 2-Emost are hypogonadalde to pititary srgeryor irradiation

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TABLE 8-15 -- DOPAMINE AGONIST TREATMENT OF PROLACTINOMAS (% OFPATIENTS)

Diso!"Bo#o$i&i'" (5-*5

#+,!.)C/"+o0i'" (5-1 #+ &2i$"

2""30.)

MICROADENOMAS

P' normalized * +*,enses resumed * +*

MACROADENOMAS

P' normalized -. *

,enses resumed +. +*

TUMOR SHRIN4AGE

/one 0* 0*

Up to .*1 2* ..

.*1 or more 2* 0.

Visual field improvement 3* *

OTHER

#ru" intolerance 4. .

P'! prolactin5

on"6actin" caber"oline has improved patient compliance and has fe7er "astrointestinal side effects5 8orfertility! bromocriptine is preferred because it is short6actin" and can be discontinued immediately on

pre"nancy confirmation5



4opamine Agonists1romocriptine, start low dose at &.2+, 2.+

mg day at night before increasing to 2.+ N&- mg per day in divided doses. 6a3e with

food to redce side eLects.

%abergoline, more eLective and with lessside eLects than 1romocriptine bt also

more e>pensive, given once or twice a wee3with a starting dose of -.2+ mg 2 > wee3

6itrate these based on prolactin levels and

tolerability



4opamine Agonists%onstipation

"asal congestion

4ry moth"ightmares

Insomnia

ertigo

"asea vomit

postral hypotension (2-E

Aditory Hallcination+E

4elsion 2EMood swings 2E

#ecopenia 6rombocitopenia



6reatment 6ranssphenoidalsrgery.

Indication SrgeryResistance &)EIntolerance 22E%ompromised ision

"ormal P#R levelsMicro *-EMacro=-E

P#R recrrence 2-E &year after srgery.

+-E Macro.

RadiotherapyAggressive tmors.



PregnancyPititary increases mass.Micro +EMacro =-E

1romocrptine has been sed in pregnancy."o teratogenic eLect reported.

Prevention 6> for PR#

1arrier contraception.

P'!NAN($!%



Microadenomas

#iscontinue dopamine a"onist 7hen pre"nancy test is positive

Periodic visual field exams durin" pre"nancy

Postpartum ,'9 after - 7ee:s

Macroadenomas

Consider sur"ery prior to pre"nancy

;nsure bromocriptine sensitivity prior to pre"nancy

8ollo7 visual fields expectantly and fre<uently

dminister bromocriptine if vision becomes compromised! or continue bromocriptine

throu"hout pre"nancy if tumor previously affected vision

Consider hi"h6dose steroids or sur"ery durin" pre"nancy if vision or threatened or if the

adenoma hemorrha"es

Postpartum ,'9 after - 7ee:s=>?

,'9! ma"netic resonance ima"in"5

P'!NAN($!%



%onclsionPititary microadenomas are common.A## pititary tmors re<ire evalation of

hormonal stats.

9ollow p and monitoring will depend on siKe andother featres of tmor4opamine agonists are the treatment of choice for

most prolactinomasSrgical intervention is initial 6O% for large tmors

and other hyperfnctional tmors G?H A%6Hsecreting



Amenorrea,galactorreaAhmada del %astillo syndrome

%hiari,9rommel Syndrome

9orbes,Albright syndrome

"OR4S https(;;rarediseases.org;rare,diseases;ahmada,del,castillo,syndrome;

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Hyper Prolactin Emi A