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Hyperprolactinemi
aHIMA San Pablo
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ObjectivesReview biological and physiological
characteristics of prolactin.
Identify mayor pathologies andpathophysiology of hormone dereglation
Analysis bene!cial treatment schedle andprognosis.
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"ormal Pititary Anatomy
. "eroendocrinology of Pititary Hormone Reglation. $ndocrinology and Metabolism %linics &'()*+,+-& &/0*
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"ormal Pititary Anatomy
ed from #echan RM. "eroendocrinology of Pititary Hormone Reglation. $ndocrinology and Metabolism %linics &'()*+,+-& &/0*
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ProlactinHman prolactin is a &// amino acid
polypeptide.
%romosome '.1lood PR# ( Monomeric 2)34 4imeric
)034 Polymeric 5&--3d. 6RH stimlate7
Half life( 2+,+- min."octrnal elevation.8idney 9iltrated.
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Prolactin
Secretion dopamine42,type receptors located on lactotrophs :a3;S6A6 molecles domain.$strogen indces #iver PR#,receptor
Receptor %hromosome +.<=#iver 1rest #iver Adrenal corte> 3idneys
Prostate Ovary 6estes Pancreatic islets 1rain#ymphocytes.
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Functions of Prolactin $ssential Hman speciesPbertyMammary glands ( 4ctal morphogenesis 6erminal end bds development( branching to networ3
dcts. I?9,& estrogens.
Pregnancy PR# serm mean 2-*g;#t
Amniotic @ids 5 &-> higher?landlar development ( Secrtory prodcts alveolar
lmina. I?9,& estrogen Progesterone hP#. Bitch mil3C
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Functions of Prolactin #actationSc3ling increased PR# levels 0>.
Mil3 prodction.#actation Amenorrhea4iminish ovlation and nmber primary follicles. Sppress 9SH #H levels Sppress 6estosterone levels sperm cont motility.
Immne#ymphocyte growth factor.
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Sellar Masses
Pititary Adenoma #ymphocytic Hypophysitis
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SIGNS AND SYMPTOMS OF PROLACTINOMAS
SIGNS AND SYMPTOMS ASSOCIATED WITH TUMOR MASS
Blurred vision or decreased visual acuity
Cranial nerve palsies
Headaches
Hydrocephalus (rare)
Pituitary apoplexy
Seizures (temporal lobe)
Symptoms of hypopituitarism
Unilateral exophthalmos (rare)
Visual field abnormalities
SIGNS AND SYMPTOMS ASSOCIATED WITH HYPERPROLACTINEMIA
menorrhea! oli"omenorrhea! primary amenorrhea! infertility
#ecreased libido! impotence! premature e$aculation! erectile dysfunction! oli"ospermia
%alactorrhea
&steoporosis
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%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
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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.
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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.
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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 '-(&)).
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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
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4opamine Agonist
6herapy
Bebster : et al. " $ngl : Med &//)J ==&(/-).
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#ong,term $Lects of 1romocriptine 6herapy
: %lin $ndocrinol Metab +-(&-2' &-==
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Sccess Rate of 1romocriptine in
AmenorrheaAfter & month of
treatment one woman infor will retrn to normalmenstral cyclingJ
In 2 months this nmberwill increase to si> ot of&-
After &- months eightot of &- women will bemenstrating normally
Of the remaining 2-Emost are hypogonadalde to pititary srgeryor irradiation
http(;;www.endote>t.com;neroendo;neroendo';neroendoframe'.htm
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TABLE 8-15 -- DOPAMINE AGONIST TREATMENT OF PROLACTINOMAS (% OFPATIENTS)
Diso!"Bo#o$i&i'" (5-*5
#+,!.)C/"+o0i'" (5-1 #+ &2i$"
2""30.)
MICROADENOMAS
P' normalized * +*,enses resumed * +*
MACROADENOMAS
P' normalized -. *
,enses resumed +. +*
TUMOR SHRIN4AGE
/one 0* 0*
Up to .*1 2* ..
.*1 or more 2* 0.
Visual field improvement 3* *
OTHER
#ru" intolerance 4. .
P'! prolactin5
on"6actin" caber"oline has improved patient compliance and has fe7er "astrointestinal side effects5 8orfertility! bromocriptine is preferred because it is short6actin" and can be discontinued immediately on
pre"nancy confirmation5
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4opamine Agonists1romocriptine, start low dose at &.2+, 2.+
mg day at night before increasing to 2.+ N&- mg per day in divided doses. 6a3e with
food to redce side eLects.
%abergoline, more eLective and with lessside eLects than 1romocriptine bt also
more e>pensive, given once or twice a wee3with a starting dose of -.2+ mg 2 > wee3
6itrate these based on prolactin levels and
tolerability
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4opamine Agonists%onstipation
"asal congestion
4ry moth"ightmares
Insomnia
ertigo
"asea vomit
postral hypotension (2-E
Aditory Hallcination+E
4elsion 2EMood swings 2E
#ecopenia 6rombocitopenia
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6reatment 6ranssphenoidalsrgery.
Indication SrgeryResistance &)EIntolerance 22E%ompromised ision
"ormal P#R levelsMicro *-EMacro=-E
P#R recrrence 2-E &year after srgery.
+-E Macro.
RadiotherapyAggressive tmors.
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PregnancyPititary increases mass.Micro +EMacro =-E
1romocrptine has been sed in pregnancy."o teratogenic eLect reported.
Prevention 6> for PR#
1arrier contraception.
P'!NAN($!%
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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($!%
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%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
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Amenorrea,galactorreaAhmada del %astillo syndrome
%hiari,9rommel Syndrome
9orbes,Albright syndrome
"OR4S https(;;rarediseases.org;rare,diseases;ahmada,del,castillo,syndrome;