Hyperprolactinemia (pituitary adenoma). Hyperprolactinemia of the pituitary gland Hyperprolactinemia without a pituitary tumor: differential diagnosis and management of patients

Excess production of prolactin (aka hyperprolactinemia) leads to serious violations. In women, this is one of the main causes of infertility, and in men - infertility and reduced potency. In patients of both sexes, it supports the course of various kinds of nervous disorders.

What is hyperprolactinemia

Hyperprolactinemia is an increase in the level of the hormone prolactin in the blood serum. Prolactin is one of the hormones of the pituitary gland, the "master conductor" of the entire endocrine system. Normally, prolactin is produced in small amounts in both men and women. In women after childbirth, prolactin production increases, which causes milk production to feed the baby.

area of ​​the pituitary gland. Adenoma (tumor) - may be the cause of increased production of pituitary hormones

Causes of hyperprolactinemia

The causes of hyperprolactinemia, which we often find during the examination:

1. Prolactinoma is an excessive increase in the number of prolactin-producing cells in the pituitary gland. Prolactinoma is usually seen on MRI scans as a microadenoma or pituitary adenoma.
2. Long-term use of antipsychotics or certain anticonvulsants.
3. Prolonged stress, sleep disturbance, nervous exhaustion.
4. Postponed brain damage (birth trauma, concussion, increased intracranial pressure, brain cyst, etc.), resulting in errors in the work of the pituitary gland.

Prolactin production can be significantly reduced or even normalized if the cause of the problem is accurately identified and appropriate treatment is carried out. This is how the treatment in our clinic will be built.

Symptoms of hyperprolactinemia

The main symptoms of hyperprolactinemia in women:

• Violation of the menstrual cycle (scanty, rare menstruation or their absence);
• Galactorrhea (occurs in 70% of women) - the release of colostrum, milk or milk-like fluid from the mammary glands;
• Decreased libido, lack of orgasm (frigidity).

The main symptoms of hyperprolactinemia in men:

• Decrease or absence of libido and potency;
• Reduction of secondary sexual characteristics (weak body hair, small size of the external genitalia, etc.);
• Infertility due to oligospermia - insufficient amount of sperm;
• Gynecomastia is a benign enlargement mammary glands in men. well seen with ultrasound of the mammary glands.

Hyperprolactinemia syndrome - this is a combination of increased production of prolactin and menstrual irregularities, infertility, galactorrhea in women, decreased libido and potency in men.

Treatment of hyperprolactinemia in the clinic "Echinacea"

Treatment in our clinic begins with a search for the causes of increased production of prolactin, if this reason has not been previously established. For a more complete understanding of the holistic picture of health, we ask patients to bring all available medical documents to the doctor's appointment, even, at first glance, not related to the current problem.

Prolactinoma, pituitary tumor,-it is a benign tumor (called an adenoma) of the pituitary gland. Pituitary- is a part of the brain that regulates the activity of various endocrine glands- thyroid gland, adrenal glands, ovaries and testicles. The pituitary gland produces a number of hormones, including prolactin, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), adrenocorticotropic hormone (ACTH), and thyroid-stimulating hormone (TSH). With the help of these hormones, the pituitary gland controls the individual endocrine glands: ACTH regulates the adrenal glands, TSH regulates the thyroid gland, FSH and LH regulate the ovaries.

Prolactinoma is one of the most common types of pituitary tumors. The results of a routine autopsy performed after a person's death showed that about a quarter (25%) of the population has small pituitary tumors.

Prolactin-secreting adenomas (prolactinomas) are the most common hormone-active pituitary tumors. Prolactinoma produces excessive amounts of the hormone prolactin. Prolactin is a natural hormone that contributes to the normal process of a woman's milk production. Prolactin stimulates breast tissue to increase during pregnancy. After the baby is born, the mother's prolactin level drops until she starts breastfeeding the baby. Every time a baby breastfeeds, prolactin levels rise and promote milk production. Normally, prolactin, LH and FSH regulate sexual life and reproduction. In women, they stimulate the formation of female sex hormones - estrogens and the maturation of the egg, and also regulate the menstrual cycle. In men, these hormones stimulate the production of the male sex hormone, testosterone, as well as sperm motility.

Symptoms of a prolactinoma (pituitary tumor)

As a result of an increased concentration of prolactin levels, the first symptom may be a violation of the rhythm of menstruation (oligo- or opsomenorrhea), up to their complete cessation (amenorrhea), since an elevated level of prolactin disrupts the formation of FSH and LH that regulate the menstrual cycle. For the same reason, infertility can be observed, which, it should be noted, is treated quite successfully. Patients often suffer from headaches. In addition, there may be a release of milk from the mammary glands (galactorrhea), which is a consequence of the physiological (natural) effect of prolactin. Galactorrhea is not a manifestation of any disease of the mammary glands, such as cancer. The risk of developing breast cancer in HH is not higher than in the absence of hyperprolactinemia, but hormonal imbalance often leads to mastopathy. In men, an excess of prolactin leads to a decrease in the level of testosterone in the blood, resulting in a decrease in interest in sexual activity (libido), impotence and infertility develop, or signs of intracranial mass formation appear. Galactorrhea for men is uncharacteristic (since the cells of the acini of the mammary glands in men do not respond to prolactin). Some women have increased facial and body hair growth (hirsutism). When the tumor is large, symptoms appear due to the pressure of the tumor on the surrounding tissues, such as headaches and visual disturbances.

Diagnostics. Etiology

Hyperprolactinemia can be caused not only by a pituitary tumor, but also by many other reasons. The reasons leading to increased production of prolactin are given below:

1. Diseases leading to dysfunction of the hypothalamus
a) infections (meningitis, encephalitis, etc.);
b) granulomatous and infiltrative processes (sarcoidosis, histiocytosis, tuberculosis, etc.);
c) tumors (glioma, meningioma, craniopharyngioma, germinoma, etc.);
d) trauma (rupture of the brain stem, hemorrhage in the hypothalamus, blockade of portal vessels, neurosurgery, radiation, etc.);
e) metabolic disorders (liver cirrhosis, chronic kidney failure).

2. Damage to the pituitary gland
a) prolactinoma (micro- or macroadenoma);
b) mixed somatotropic-prolactin adenoma;
c) other tumors (somatotropinoma, corticotropinoma, thyrotropinoma, gonadotropinoma);
d) syndrome of an empty Turkish saddle;
e) craniopharyngioma;
f) hormonally inactive or "silent" adenoma;
g) intrasellar germinoma, meningioma, cyst or cyst of Rathke's pouch.

3. Other diseases
a) primary hypothyroidism;
b) ectopic secretion of hormones;
c) polycystic ovary syndrome;
d) chronic renal failure;
e) cirrhosis of the liver;
f) damage chest: herpes zoster, etc., stimulation of the mammary gland.

4. Pharmacological preparations
a) dopamine blockers: sulpiride, metoclopramide, domperidone, antipsychotics, phenothiazides;
b) antidepressants: imipramine, amitriptyline, haloperidol;
c) calcium channel blockers: verapamil;
d) adrenergic inhibitors: reserpine, a-methyldopa, aldomet, carbidopa, benserazide;
e) estrogens: pregnancy, taking contraceptives, taking estrogen for therapeutic purposes;
f) H2 receptor blockers: cimetidine;
g) opiates and cocaine;
h) thyroliberin.

To exclude hypothyroidism, pregnancy and renal failure, an examination and simple laboratory tests are sufficient. Particular attention is paid to the drug history. It is believed that the use of oral contraceptives does not increase the risk of formation and growth of prolactinomas.

Laboratory diagnostics

It is recommended to measure serum prolactin levels three times in different days to eliminate random or stress-related fluctuations in hormone levels. A prolactin concentration of more than 200 ng / ml almost always indicates the presence of a prolactinoma (normally in men, the level of prolactin is less than 15 ng / ml, in women it is less than 20 ng / ml). Prolactinomas come in a variety of sizes, but the vast majority are less than 10 mm in diameter and are called microprolactinomas. Much less common are prolactinomas of 10 mm or more, which are called macroprolactinomas. Symptoms of prolactinoma depend on both the sex of the patient and the size of the tumor. The level of prolactin correlates with the size of the tumor, therefore, with microprolactinoma, hyperprolactinemia may not be so pronounced. A slight increase in the level of prolactin (up to 30-50 ng / ml) may be due to both microprolactinomas and functional disorders of the hypothalamic-pituitary system.
An MRI of the pituitary gland is required to confirm a pituitary tumor.

Treatment of prolactinoma

Drug treatment of prolactinoma is the method of choice for most patients with prolactinomas. Ergot derivatives (bromocriptine, lisuride and pergolide) reliably suppress prolactin secretion, eliminate galactorrhea and restore the function of the gonads in most patients with hyperprolactinemia of any etiology. In addition, bromocriptine and related drugs cause the regression of prolactinomas in 60-80% of patients (although tumors usually do not disappear completely).

Thus, drug treatment either avoids surgery or makes the operation less difficult (by shrinking large tumors).

Treatment with bromocriptine usually begins with low doses: 1.25-2.5 mg / day orally (with 1/2 tab. or 1 tab.), at bedtime, with meals (to prevent nausea and orthostatic hypotension). The dose is increased by 1.25 or 2.5 mg every 3-4 days until the desired daily dose is reached (usually 5-10 mg, in 2-3 divided doses with meals). Some patients require even higher doses. This treatment helps to reduce the production of prolactin by the tumor, the level of which in the blood often drops to normal within a few weeks after the start of treatment. In women, as prolactin normalizes, the menstrual cycle and the ability to conceive are restored. Pregnancy, by the way, can occur quite quickly, so if you are not planning to have a baby at this time, you should discuss with your doctor the most appropriate method of contraception.

In men, along with a decrease in prolactin levels, testosterone levels increase, which normalizes the quality of sexual life. Against the background of taking parlodel, almost all prolactinomas decrease in size, and vision may even improve. Bromocriptine is interrupted every 2-3 years and the need to continue therapy is assessed. In a small number of patients, hyperprolactinemia disappears a few years after the start of treatment.

Quinagolide (norprolac) differs in structure from bromocriptine and is therefore well tolerated by those in whom bromocriptine causes side effects. Norprolac is taken once a day at night.
There is another drug - cabergoline (dostinex), the peculiarity of which is that it is taken 1-2 times a week.

Radical treatments for pituitary tumors

In relation to efficiency drug treatment with prolactinomas, they rarely resort to operations and radiation therapy. Only a minority of patients with macroprolactinomas who do not shrink with medical treatment may need surgery, especially if their vision does not improve. It should be noted that this operation is currently performed through a small incision near the sinuses, the so-called transsphenoidal approach. If a large prolactinoma steadily decreases in size as a result of taking pills, then this method continues in the future.

Sometimes experts recommend radiation therapy, which allows you to stop taking the medicine. The effect of irradiation develops gradually and fully manifests itself only after a few years, therefore, radiation therapy is not prescribed to young women who want to become pregnant (these women predominate among patients with prolactinomas). With microprolactinomas, selective transsphenoidal adenomectomy is most often performed, however, in 20-50% of patients for 5 years after surgery, the tumor recurs and hyperprolactinemia resumes. With macroprolactinomas, even a short-term initial improvement after surgery occurs in only 10-30% of patients.

During radiation therapy or surgical treatment, it is possible to develop pituitary insufficiency, as a result of which secondary adrenal insufficiency and hypothyroidism develop, and replacement therapy is required - glucocorticoids in the presence of adrenal insufficiency, L-thyroxine in the presence of thyroid insufficiency (hypothyroidism) and, possibly, sex hormones (estrogens for women and testosterone for men) as replacement therapy.

Bromocriptine and pregnancy

To date, there is no evidence that the use of bromocriptine before or during pregnancy increases the incidence of spontaneous abortions, stillbirths and fetal abnormalities. If pregnancy is established, bromocriptine is usually discontinued, so it is possible for the prolactinoma to re-grow. Despite the fact that an excess of estrogens during pregnancy causes hyperplasia of the lactotropic cells of the adenohypophysis, a clinically significant increase in the growth of microprolactinomas is rarely observed (in 3-5% of patients). Pregnant women with macroprolactinomas have a slightly higher risk of complications. If significant tumor growth occurs during pregnancy, accompanied by headaches and visual impairment, resort to early delivery or resume taking bromocriptine. Thus, women with microadenomas can become pregnant if they wish, but they should be aware that there is a risk (albeit small) of accelerated tumor growth during pregnancy. Prophylactic irradiation of the pituitary before conception in microadenomas is not recommended; with large tumors, it may be useless. Radiation therapy does not affect the effectiveness of treatment with bromocriptine.

For women who do not want children, and for men, radiation therapy or surgery may be the treatment of choice. Decreased libido and impotence in men due to hyperprolactinemia are not always amenable to testosterone treatment. Medications or other methods may be needed to normalize prolactin levels. Dispensary observation of an endocrinologist for such patients requires lifelong.

Hyperprolactinemia syndrome is a symptom complex caused by excessive secretion of prolactin by the pituitary gland, accompanied by hypogonadism and galactorrhea.

Etiology and pathogenesis

Allocate physiological and pathological hyperprolactinemia. Physiological hyperprolactinemia develops during pregnancy, lactation, and in newborns. Pathological hyperprolactinemia may be due to:

1. primary isolated hyperproduction of prolactin by the pituitary gland - due to prolactinoma (micro- or macroadenomas of the pituitary gland) or isolated hyperproduction of prolactin by the pituitary gland without the presence of local changes in the pituitary gland (essential hyperprolactinemia);
2. combinations of hyperprolactinemia with other diseases of the hypothalamic-pituitary system (somatotropinomas, corticotropinomas, gonadotropinomas, thyrotropinomas, inactive pituitary adenomas, craniopharyngiomas, meningiomas, gliomas, sarcoidosis, histiocytosis X, autoimmune lymphocytic hypophysitis, etc.);
3. symptomatic hyperprolactinemia in diseases of the endocrine system (primary, polycystic ovary syndrome, estrogen-producing tumors, congenital dysfunction of the adrenal cortex);
4. symptomatic hyperprolactinemia in liver and kidney failure;
5. iatrogenic hyperprolactinemia:
   • antidopaminergic drugs - neuroleptics and antiemetics;
   • exhaustive reserves of dopamine - reserpine;
   • dopamine synthesis inhibitors - methyldopa, levopa, carbidora;
   • drugs - opiates, morphine, cocaine, heroin;
   • antagonists of histamine H 2 receptors - cimetidine, ranitidine, famotidine;
   • tricyclic antidepressants;
   • monoamine oxidase uptake inhibitors - amitriptyline, melipramine, anafranil, arorix;
   • serotonergic drugs - amphetamines, hallucinogens;
   • estrogen-containing drugs;
   • calcium antagonists - verapamil;
6. symptomatic hyperprolactinemia in female athletes.

According to the severity, asymptomatic and manifest hyperprolactinemia are distinguished.

Long-term stable hyperprolactinemia leads to blockade of the cyclical secretion of LH and FSH by the pituitary gland and the development of ovarian dysfunction, hypoestrogenism, anovulation and menstrual disorders in women (hyperprolactinemic hypogonadism). In men, libido decreases as a result of hyperprolactinemia. In addition, there is a direct effect of hyperprolactinemia - galactorrhea. Since the syndrome of hyperprolactinemia is realized through hypogonadism, the main pathogenetic effects are due to estrogen deficiency.

Symptoms

Clinical manifestations of hyperprolactinemia syndrome are highly variable, but include 2 main clinical manifestations: hypogonadism and galactorrhea.

Since the syndrome of hyperprolactinemia is more often recorded in women, its main manifestations vary depending on the age of manifestation of the disease or period of life. In puberty - that is a delay in menarche, an irregular menstrual cycle, less often -. In women, the main complaint is menstrual disorders according to the type of oligoopsomenorrhea up to amenorrhea (in most cases secondary), infertility (primary or secondary). At the beginning of the disease, it is possible to maintain menstruation with an anovulatory cycle. When pregnancy occurs, spontaneous abortions are possible in early term pregnancy.

The social significance of these manifestations of the syndrome of hyperprolactinemia leads to a rare fixation of the attention of patients to other complaints: decreased libido, impaired orgasm up to anorgasmia, dryness of the vaginal mucosa and difficulty in sexual intercourse. About 25% of patients note slightly pronounced hirsutism (excessive hair growth on the face, around the nipples, along the white line of the abdomen). With the manifestation of the disease in the postpartum period, the main complaint is incessant lactation, which is often accompanied by a decrease in body weight. Gynecological examination reveals signs characteristic of the age period of development of hypogonadism.

In men, the symptoms of hypogonadism in most cases are manifested by a decrease in libido and potency (erectile dysfunction), infertility (due to oligospermia). May reduce the severity of secondary sexual characteristics.

The second group of symptoms is associated with the appearance of galactorrhea. The severity of galactorrhea varies from single drops with pressure on the nipple halo (detected only upon examination) to abundant spontaneous lactorrhoea, accompanied by obvious complaints. With the course of the disease, the intensity of lactorrhoea decreases, which is due to involutive changes in the mammary glands and the replacement of the glandular tissue with adipose tissue. Macromastia for hyperprolactinemia is not a characteristic syndrome. With the manifestation of the disease in the pubertal period, the development of the mammary glands stops at the level of development of the juvenile mammary gland. In men, gynecomastia and galactorrhea are possible, but not required.

With the syndrome of hyperprolactinemia due to the development of micro- or macroadenoma of the pituitary gland, neurological symptoms may appear: headaches, dizziness, visual impairment, symptoms of intracranial hypertension. The severity of neurological symptoms is directly dependent on the size of the pituitary adenoma. In women, the frequency of pituitary macroadenomas, accompanied by neurological symptoms, is recorded much less frequently than in men. In addition, the development of metabolic disorders of a secondary nature can be noted - a decrease in bone mineral density and bone mass with the development of osteopenia or osteoporosis; insulin resistance.

Diagnostics

The diagnosis of hyperprolactinemia syndrome is established by comparing complaints, the results of a clinical examination and laboratory tests.

The main laboratory sign is an increase in the level of prolactin:

• in men - more than 20 ng / ml or 400 mU / l
• in women - more than 25 ng / ml or 500 mU / l.

When detecting hyperprolactinemia more than 200 ng / ml or 4000 mU / l, it should be borne in mind that such levels of prolactin are most characteristic of pituitary macroadenoma. In doubtful cases, stimulation pharmacological tests can be used, but their information content is low.

Test with thyroliberin (200 - 500 mcg intravenously): in healthy people, the level of prolactin increases after 15 - 30 minutes by more than 100% of the original, and in the presence of adenoma, there is no increase or its degree is significantly lower.

Test with metoclopramide (metoclopramide 10 mg intravenously): in healthy people, the level of prolactin increases after 15-30 minutes by 10-15 times from the initial level, and in the presence of adenoma, there is no increase or its degree is significantly lower (when metoclopramide is prescribed at a dose of 20 mg orally, the duration of the test increases to 4 hours).

After determining the level of prolactin, the anamnesis is carefully analyzed to exclude, first of all, symptomatic and iatrogenic hyperprolactinemia, which allows determining a further examination plan (assessment of the functional state of the thyroid gland, assessment of the function and structure of the ovaries, testicles and prostate gland, liver and night function, etc. ). To exclude symptomatic and iatrogenic forms of hyperprolactinemia, visualization of the pituitary gland is performed to identify micro- or microadenomas of the pituitary gland and to establish the cause of primary or combined with other hypothalamic-pituitary hyperprolactinemia pathology. MRI is the optimal method for visualizing the pituitary gland (CT is slightly less informative).

The differential diagnosis is made with various forms infertility, volumetric processes of the hypothalamic-pituitary zone, primary hypothyroidism, etc.

Treatment

The main method of treatment is a semi-synthetic ergot alkaloid dopamine agonist - bromocriptine, which has a blocking effect on the release of prolactin and reduces the frequency of mitosis in prolactotrophs, causing a slowdown in the growth of pituitary adenomas and a reduction in their size. Restoration of prolactin secretion leads to the normalization of cyclic rhythms of secretion of hormones of the hypothalamus, pituitary gland and sexual function. Bromkriptin is prescribed at a dose of 1.25-10 mg / day (rarely, the required dose of bromocriptine reaches 20 mg / day). The daily dose is divided into at least 2 doses (duration of action 12 hours) and is determined by the degree of decrease in the level of prolactin, which is controlled by titrating the vine 1 time in 2 weeks.

Side effects (weakness, nausea, dizziness, orthostatic hypotension) in most cases do not require discontinuation of the drug and decrease with the appointment of antidopaminergic antiemetic drugs (metoclopramide).

With the normalization of the level of prolactin, fertility is restored, therefore, pregnancy is possible, which patients should be warned about. When pregnancy occurs, bromocriptine is canceled, despite the evidence of the absence of teratogenic and abortive effects. The exception is women who develop symptoms of pituitary adenoma growth during pregnancy (chiasmatic syndrome).

An alternative method of treatment is the appointment of cabergoline at a dose of 0.25-4.5 mg per week. Given the duration of the drug (half-life is 68 hours in healthy people and reaches 115 hours in patients with hyperprolactinemia), cabergoline is taken 2-3 times a week. At the beginning of cabergoline therapy, a pregnancy test should be performed, since the drug is contraindicated in pregnancy. After the restoration of the menstrual cycle when planning pregnancy, treatment with cabergoline should be discontinued (the absence of negative effects on the fetus has not been proven).

When treated with dopamine agonists, drug remission of the disease is achieved in most cases. 5-10% of pituitary adenomas regress during treatment with bromocriptine or cabergoline (less often spontaneously), so every 2-3 years treatment should be stopped for 1-3 months, the diagnosis should be reclassified and the need to continue therapy should be determined. Monitoring MRI of the pituitary gland is recommended to be carried out 2 times a year upon detection of the diagnosis and then - 1 time per year.

In the absence of fertility restoration against the background of normalization of prolactin levels, additional therapy is recommended - ovulation stimulation with clomiphene or gonadotropins, antiandrogens in women, androgens in men.

If medical treatment fails, surgery may be recommended. The limited indications for surgical treatment, despite the widespread use of transsphenoidal access to the tumor, is due to the high recurrence rate (more than 30%).

Indications for surgical treatment:

• refractoriness to dopamine agonists (the need for a dose of bromocriptine exceeds 20 mg / day or cabergoline 3.5 mg);
• intolerance to dopamine agonists;
• pituitary adenomas with suprasellar growth and signs of chiasm compression and/or increased intracranial pressure;
• tumors of the hypothalamic-pituitary zone with germination in the sphenoidal sinus and / or accompanied by liquorrhea.

Forecast

The prognosis for life is favorable. In most cases, fertility is restored. Long-term remissions after pregnancy are observed in 20% of cases or more.

Hyperprolactinemia It is a condition in which the level of the hormone prolactin is elevated in the blood. An increase in prolactin during pregnancy is considered normal. breastfeeding(prolactin promotes milk production).

After the cessation of breastfeeding, the level of the hormone prolactin in a woman returns to normal. In the case when the level of prolactin does not increase during pregnancy and lactation, they speak of the development of hyperprolactinemia.

The very first sign of hyperprolactinemia- This is a violation of the menstrual cycle: from minor delays to the complete cessation of menstruation. This is because elevated prolactin levels affect the synthesis of follicle-stimulating hormone and luteinizing hormone (FSH and LH, respectively), which regulate the menstrual cycle. Often it is elevated prolactin that causes infertility in women. Also, elevated prolactin can cause headaches, a decrease in the function of sexual desire.

In 30% of cases, with increased prolactin in women who are not in the lactation period, milk begins to be released from the mammary glands. This condition is called galactorrhea. Galactorrhea is not a symptom of a disease of the mammary glands, such as benign or malignant tumors, but is a consequence of an increase in the level of prolactin in the blood.

Hirsutism, acne, hyperandrogenism (increased levels of male sex hormones) - these disorders are observed in 25% of women suffering from hyperprolactinemia.

Reasons for the development of hyperprolactinemia.

The hormone prolactin in a woman's blood can increase due to various causative factors. It can even be a slight stress before taking a blood test, as well as excitement before a gynecological examination, a study of the mammary glands. Even the slightest excitement leads to a short-term increase in the level of prolactin in the blood.

In addition to stressful situations, hormone production is affected by taking medicines such as neuroleptics, antiemetics, opiates, estrogens, contraceptives. If an elevated level of prolactin in the blood is detected, it is necessary to indicate to the doctor which drugs were taken shortly before the test.

Also, the causative factors of an increased level of prolactin include transferred radiation exposure, operations on the organs of the chest and mammary glands, syndrome of an empty Turkish saddle.

Various diseases, such as chronic renal failure, chronic liver failure, hypothyroidism (deficiency of thyroid function) and other diseases of the endocrine system (polycystic ovary syndrome, Itsenko-Cushing's disease), in turn, are a trigger for the development of hyperprolactinemia.

In addition to diseases of the endocrine system and non-endocrine diseases, the development of hyperprolactinemia is affected by the presence of benign tumor hypothalamic-pituitary region (i.e. pituitary adenomas). The adenoma produces prolactin, while tumor growth is either very slow or non-existent. To date, medicine has not been able to fully elucidate the causes that affect the occurrence of pituitary adenomas.

A common cause of hyperprolactinemia is the presence of microprolactinomas and macroprolactinomas (up to 10 mm and over 10 mm in diameter, respectively). In 20-25% of women diagnosed with infertility and menstrual irregularities, elevated levels of prolactin are found. In 40-45% of cases, a pituitary tumor causes hyperprolactinemia.

In addition, it should be noted that elevated prolactin in the blood can be detected in the absence of the above pathologies. This form of hyperprolactinemia is called idiopathic or functional. The cause of this type of hyperprolactinemia is the increased function of the cells that secrete prolactin.

Diagnosis of the disease.

Diagnosis of hyperprolactinemia is carried out in the following stages:

Plasma analysis to determine the level of prolactin
x-ray of the head (craniogram)
computed tomography or nuclear magnetic resonance imaging of the head (NMR)
study of visual fields and fundus

If an elevated level of prolactin in the blood is detected and there are no signs of hyperprolactinemia according to the results of other studies, the blood test is repeated to rule out an erroneous diagnosis. Before taking a blood test, you must follow a certain diet the day before (excluding fatty, salty and spicy foods), the test is carried out from 9 to 12 in the morning on an empty stomach. A woman should have a good rest before taking the test, try not to worry, refrain from sexual intercourse the day before.

In the case of a double detection of elevated prolactin in the blood, a diagnosis of hyperprolactinemia is made. Most laboratories define the upper limit of normal for prolactin as 500 mIU/L or 25 ng/mL.

Different levels of prolactin can to some extent indicate the cause of the disease: if the level of prolactin is more than 200 ng / ml, then this usually indicates the presence of a pituitary macroadenoma. If the level of prolactin is less than 200 ng / ml, then there is a high probability of the presence of pituitary microadenomas, or idiopathic hyperprolactinemia.

In addition to determining the level of the hormone prolactin in the blood, it is also necessary to check the level of other hormones and necessarily the function of the thyroid gland.

The patient should have a craniogram to examine the Turkish saddle. An enlarged sella turcica is found in 20% of patients, as well as an expansion of the entrance to the sella turcica and a double bottom, which is a sign of the presence of a microadenoma (prolactenoma) of the pituitary gland. In the event that the craniogram does not reveal any abnormalities, the patient is assigned a computed tomography or nuclear magnetic resonance imaging to detect pituitary microprolactinomas (which are less than 10 mm in size).

When confirming the presence of a macroadenoma, the patient is prescribed an examination of the fundus and visual fields in order to determine the spread of the tumor outside the Turkish saddle (at the optic chiasm).

Treatment of the disease.

Treatment of hyperprolactinemia is carried out:

Medically
radiation therapy
surgical intervention

If hyperprolactinemia is caused by the presence of a pituitary microadenoma or an idiopathic increase in the hormone prolactin, then the main treatment is the use of dopamine agonists, which reduce the secretion of prolactin. With this treatment, prolactin levels often drop to normal levels within a few weeks of starting treatment.

Dopamine agonists are prescribed according to a certain scheme, i.e. courses lasting 6-24 months. During the intake of prolactin, dynamic monitoring of the level of prolactin and basal temperature is carried out. As treatment progresses, prolactin levels return to normal, menstrual function (including ovulation) is restored in 80% of cases, and pregnancy occurs in 70%.

When taking medications, almost all prolactinomas decrease in size.

In the case of a pituitary macroadenoma, the treatment is discussed jointly with a gynecologist and a neurosurgeon.

The effectiveness of drug treatment is quite high, so radiation therapy and surgery are rarely used. A small percentage of patients in whom the size of the macroadenoma does not decrease with medication still need surgical treatment.

During the operation, a small incision is made near the sinuses. In some cases, doctors recommend a course of radiation therapy, which makes it possible to stop taking the drugs, but this does not eliminate the risk of developing pituitary insufficiency.

The list of medications prescribed for the treatment of hyperprolactinemia also includes hormonal agents: glucocorticoids (in the presence of adrenal insufficiency), L-thyroxine (in the presence of thyroid insufficiency), as well as estrogens (sex hormones) in the form of replacement therapy.

Women diagnosed with hyperprolactinemia should be constantly monitored by a doctor.

Most often, hyperprolactinemia occurs in young women aged 25-40 years, much less often in men of the same age.

Causes

The reasons leading to an increase in the production of prolactin are varied:

1. Tumor (adenoma) of the pituitary gland common cause this state. Usually such tumors are small in size (no more than 2-3 mm). The word "tumor" doctors mean an increase in the size of the pituitary gland, this is not cancer, but a benign formation.
2. Decreased thyroid function (hypothyroidism).
3. Diseases of the ovaries (polycystic ovary syndrome).
4. Taking certain drugs: antiemetics (cerucal), antidepressants (amitriptyline), contraceptives with a high content of estrogen.
5. Cirrhosis of the liver.
6. Chronic renal failure (hyperprolactinemia occurs in 65% of patients on hemodialysis).
7. Brain diseases (meningitis, encephalitis, tumors).

What's happening?

Women with hyperprolactinemia syndrome, as a rule, are concerned about the secretion of milk from the mammary glands outside of pregnancy (galactorrhea), infertility and menstruation (most often their absence). Men are preoccupied with a decrease in sexual desire and potency, sometimes in combination with the release of milk. In some cases, there is excessive growth of body hair, a tendency to acne. As the pituitary tumor grows, visual impairment and headache may occur.

Diagnosis and treatment

Diagnosis and treatment of hyperprolactinemia is carried out by an endocrinologist, as well as a gynecologist-endocrinologist.

For diagnostics it is necessary:

• take a blood test for prolactin (blood is taken from a vein), in addition, the doctor may prescribe hormonal tests;
• in some cases, you will need to take a blood test for other hormones, for example, thyroid hormones (if the doctor suspects thyroid dysfunction);
• perform an x-ray of the skull and the sella turcica to assess the size of the pituitary gland;
• for a detailed assessment of the pituitary gland and surrounding parts of the brain, tomography is used - computed (CT), based on the use of x-rays, and magnetic resonance imaging (MRI), based on the use of magnetic fields;
• gynecologist consultation (for women);
• if a pituitary adenoma is detected, an ophthalmologist's consultation will be required.

If hyperprolactinemia is caused by hypothyroidism or adrenal insufficiency, appropriate hormone replacement therapy is prescribed, which leads to the normalization of prolactin production and the cessation of galactorrhea.

If the condition is associated with taking medications (cerucal, amitriptyline, etc.), these drugs are canceled. As a rule, 4-5 weeks after this, the menstrual cycle is restored and galactorrhea stops.

Therapeutic treatment is used most often. Patients are prescribed special drugs (parlodel, lizurid, etc.). Such therapy normalizes the content of prolactin in the blood, in women it restores the menstrual cycle and the ability to conceive.

Surgical intervention (removal of a pituitary tumor) is used, as a rule, in the presence of visual impairment and insufficient effectiveness of therapeutic treatment.

Radiation therapy is used most often as an additional method of treatment after hypophysectomy or against the background of therapeutic treatment.