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Prolactinoma

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Prolactinoma
SpecialtyOncology, endocrinology, neurology, neurosurgery Edit this on Wikidata

A prolactinoma is a benign tumor (adenoma) of the pituitary gland that produces a hormone called prolactin. It is the most common type of functioning pituitary tumor.[1] Symptoms of prolactinoma are due to too much prolactin in the blood (hyperprolactinemia), or those caused by pressure of the tumor on surrounding tissues.

Prolactin stimulates the breast to produce milk and has many other functions such as regulation of mood. Hence prolactin levels are usually higher during pregnancy and after childbirth. After delivery of a baby, a mother's prolactin levels come down to normal a few weeks after breastfeeding is discontinued. Each time the milk is dispensed, prolactin levels rise; this process may cycle to maintain milk production. In males, prolactin is responsible for the sexual refractory period after orgasm and excess levels can lead to erectile dysfunction.[2]

Based on size, a prolactinoma can be classified as a microprolactinoma (<10 mm diameter) or macroprolactinoma (>10 mm diameter).

Signs and symptoms

See also: Hyperprolactinaemia

The symptoms due to a prolactinoma are broadly divided into those that are caused by increased prolactin levels or mass effect.

Those that are caused by increased prolactin levels are:[3]

Those that are caused by mass effect are:

  • Headaches[5]
  • Vision Changes-visual field deficits, blurred vision, decreased visual acuity[5]
  • Cranial nerve palsies-especially with invasive tumors or with pituitary apoplexy[5]
  • Seizures, Hydrocephalus, Unilateral exophthalmos are rare presentations[5]
  • Pituitary apoplexy is a medical emergency because of spontaneous hemorrhage into the pituitary tumor and presents with severe headaches, vision changes, and panhypopituitarism.[5]

Causes

The cause of pituitary tumors remains unknown. It has been shown that stress can significantly raise prolactin levels, which should make stress a diagnostic differential, though it usually is not considered such. Most pituitary tumors are sporadic — they are not genetically passed from parents to offspring.[citation needed]

The majority of moderately raised prolactin levels (up to 5000 mIU/L) are not due to microprolactinomas but other causes. The effects of some prescription drugs are the most common. Other causes are other pituitary tumours and normal pregnancy and breastfeeding. This is discussed more under hyperprolactinaemia.[6]

The xenoestrogenic chemical Bisphenol-A has been shown to lead to hyperprolactinaemia and growth of prolactin-producing pituitary cells.[7] The increasing and prolonged exposure of Bisphenol-A from childhood on, may contribute to the growth of a Prolactinoma.[citation needed]

Diagnosis

A doctor will test for prolactin blood levels in women with unexplained milk secretion (galactorrhea) or irregular menses or infertility, and in men with impaired sexual function and, in rare cases, milk secretion. If prolactin is high, a doctor will test thyroid function and ask first about other conditions and medications known to raise prolactin secretion. The doctor will also request a magnetic resonance imaging (MRI), which is the most sensitive test for detecting pituitary tumors and determining their size. MRI scans may be repeated periodically to assess tumor progression and the effects of therapy. Computed Tomography (CT scan) also gives an image of the pituitary, but it is less sensitive than the MRI.[8]

In addition to assessing the size of the pituitary tumor, doctors also look for damage to surrounding tissues and perform tests to assess whether production of other pituitary hormones is normal. Depending on the size of the tumor, the doctor may request an eye exam with measurement of visual fields.[citation needed]

Treatments

The goal of treatment is to return prolactin secretion to normal, reduce tumor size, correct any visual abnormalities, and restore normal pituitary function. As mentioned above, the impact of stress should be ruled out before the diagnosis of prolactinoma is given. Exercise can significantly reduce stress and, thereby, prolactin levels. In the case of very large tumors, only partial reduction of the prolactin levels may be possible.[9]

Medications

Dopamine is the chemical that normally inhibits prolactin secretion, so clinicians may treat prolactinoma with drugs that act like dopamine such as bromocriptine and cabergoline.[10] This type of drug is called a dopamine agonist.[10] These drugs shrink the tumor and return prolactin levels to normal in approximately 80% of patients. Both bromocriptine and cabergoline been approved by the Food and Drug Administration for the treatment of hyperprolactinemia. Bromocriptine is associated with side-effects such as nausea and dizziness and hypotension in patients with already low blood pressure readings. To avoid these side-effects, it is important for bromocriptine treatment to start slowly.[11]

Bromocriptine treatment should not be interrupted without consulting a qualified endocrinologist. Prolactin levels often rise again in most people when the drug is discontinued. In some, however, prolactin levels remain normal, so the doctor may suggest reducing or discontinuing treatment every two years on a trial basis. Recent studies have shown increased success in remission of prolactin levels after discontinuation, in patients having been treated for at least 2 years prior to cessation of bromocriptine treatment.[12]

Cabergoline is also associated with side effects such as nausea and dizziness, but these may be less common and less severe than with bromocriptine. However, people with low blood pressure should use caution when starting cabergoline treatment, as the long half-life of the drug (4–7 days) may inadvertently affect their ability to keep their blood pressure within normal limits, creating intense discomfort, dizziness, and even fainting upon standing and walking until the single first dose clears from their system. As with bromocriptine therapy, side effects may be avoided or minimized if treatment is started slowly. If a patient's prolactin level remains normal for 6 months, a doctor may consider stopping treatment. Cabergoline should not be interrupted without consulting a qualified endocrinologist.[citation needed]

Other dopamine agonists that have been used less commonly to suppress prolactin include dihydroergocryptine, ergoloid, lisuride, metergoline, pergolide, quinagolide, and terguride.[10]

Surgery

Surgery should be considered if medical therapy cannot be tolerated or if it fails to reduce prolactin levels, restore normal reproduction and pituitary function, and reduce tumor size. If medical therapy is only partially successful, this therapy should continue, possibly combined with surgery or radiation treatment.[13]

The results of surgery depend a great deal on tumor size and prolactin level. The higher the prolactin level the lower the chance of normalizing serum prolactin. In the best medical centers, surgery corrects prolactin levels in 80% of patients with a serum prolactin less than 250 ng/ml. Even in patients with large tumors that cannot be completely removed, drug therapy may be able to return serum prolactin to the normal range after surgery. Depending on the size of the tumor and how much of it is removed, studies show that 20 to 50% will recur, usually within five years.[citation needed]

Prognosis

People with microprolactinoma generally have an excellent prognosis. In 95% of cases, the tumor will not show any signs of growth after a 4 to 6-year period.[citation needed]

Macroprolactinomas often require more aggressive treatment otherwise they may continue to grow. There is no way to reliably predict the rate of growth, as it is different for every individual. Regular monitoring by a specialist to detect any major changes in the tumor is recommended.[citation needed]

Osteoporosis risk

Hyperprolactinemia can cause reduced estrogen production in women and reduced testosterone production in men. Although estrogen/testosterone production may be restored after treatment for hyperprolactinemia, even a year or two without estrogen/testosterone can compromise bone strength, and patients should protect themselves from osteoporosis by increasing exercise and calcium intake through diet or supplementation, and by avoiding smoking. Patients may want to have bone density measurements to assess the effect of estrogen/testosterone deficiency on bone density. They may also want to discuss testosterone/estrogen replacement therapy with their physician.[citation needed]

Pregnancy and oral birth control

If a woman has one or more small prolactinoma, there is no reason that she cannot conceive and have a normal pregnancy after successful medical therapy. The pituitary enlarges and prolactin production increases during normal pregnancy in women without pituitary disorders. Women with prolactin-secreting tumors may experience further pituitary enlargement and must be closely monitored during pregnancy. However, damage to the pituitary or eye nerves occurs in less than one percent of pregnant women with prolactinoma. In women with large tumors, the risk of damage to the pituitary or eye nerves is greater, and some doctors consider it as high as 25%. If a woman has completed a successful pregnancy, the chances of her completing further successful pregnancies are extremely high.[citation needed]

A woman with a prolactinoma should discuss her plans to conceive with her physician, so she can be carefully evaluated prior to becoming pregnant. This evaluation will include a magnetic resonance imaging (MRI) scan to assess the size of the tumor and an eye examination with measurement of visual fields. As soon as a patient is pregnant, her doctor will usually advise that she stop taking bromocriptine or cabergoline, the common treatments for prolactinoma. Most endocrinologists see patients every two months throughout the pregnancy. The patient should consult her endocrinologist promptly if she develops symptoms — in particular, headaches, visual changes, nausea, vomiting, excessive thirst or urination, or extreme lethargy. Bromocriptine or cabergoline treatment may be renewed and additional treatment may be required if the patient develops symptoms from growth of the tumor during pregnancy.[citation needed]

At one time, oral contraceptives were thought to contribute to the development of prolactinomas. However, this is no longer thought to be true. Patients with prolactinoma treated with bromocriptine or cabergoline may also take oral contraceptives. Likewise, post-menopausal estrogen replacement is safe in patients with prolactinoma treated with medical therapy or surgery.[citation needed]

Epidemiology

Autopsy studies indicate that 6-25% of the U. S. population have small pituitary tumors.[14] Forty percent of these pituitary tumors produce prolactin, but most are not considered clinically significant. Clinically significant pituitary tumors affect the health of approximately 14 out of 100,000 people. In non-selective surgical series, this tumor accounts for approximately 25-30% of all pituitary adenomas.[15] Some growth hormone (GH)–producing tumors also co-secrete prolactin. Microprolactinomas are much more common than macroprolactinomas.[citation needed]

See also

References

  1. ^ Glezer A, Bronstein MD (2015). "Prolactinomas". Endocrinol Metab Clin North Am. 44 (1): 71–78. doi:10.1016/j.ecl.2014.11.003. PMID 25732643.
  2. ^ Baltzar MT, Anholm C, Petersen CD (June 2012). "[Hyperprolactin as cause of hypoactive sexual desire in men]". Ugeskrift for Lægerer. 174 (25): 1745–6. PMID 22713225.
  3. ^ "Prolactinoma - PubMed Health". Ncbi.nlm.nih.gov. Retrieved 2012-05-28.
  4. ^ "Gynecomastia". The Lecturio Medical Concept Library. Retrieved 24 July 2021.
  5. ^ a b c d e Yatavelli RK, Bhusal K (2020). "Prolactinoma". StatPearls. PMID 29083585.
  6. ^ Mancini T, Casanueva FF, Giustina A (March 2008). "Hyperprolactinemia and prolactinomas". Endocrinology and Metabolism Clinics of North America. 37 (1): 67–99, viii. doi:10.1016/j.ecl.2007.10.013. PMID 18226731.
  7. ^ Goloubkova T, Ribeiro MF, Rodrigues LP, Cecconello AL, Spritzer PM (April 2000). "Effects of xenoestrogen bisphenol A on uterine and pituitary weight, serum prolactin levels and immunoreactive prolactin cells in ovariectomized Wistar rats". Arch. Toxicol. 74 (2): 92–8. doi:10.1007/s002040050658. PMID 10839476. S2CID 11666372.[permanent dead link]
  8. ^ "Prolactinoma". National Institute Of Diabetes And Digestive And Kidney Diseases. Retrieved 24 July 2021.
  9. ^ "Prolactinoma". National Institute Of Diabetes And Digestive And Kidney Diseases. Retrieved 24 July 2021.
  10. ^ a b c Bankowski BJ, Zacur HA (June 2003). "Dopamine agonist therapy for hyperprolactinemia". Clin Obstet Gynecol. 46 (2): 349–62. doi:10.1097/00003081-200306000-00013. PMID 12808385.
  11. ^ "Prolactinoma". National Institute Of Diabetes And Digestive And Kidney Diseases. Retrieved 24 July 2021.
  12. ^ Bronstein MD (March 2006). "Potential for long-term remission of microprolactinoma after withdrawal of dopamine-agonist therapy". Nat Clin Pract Endocrinol Metab. 2 (3): 130–1. doi:10.1038/ncpendmet0135. PMID 16932269. S2CID 10873443.
  13. ^ "Prolactinoma". National Institute Of Diabetes And Digestive And Kidney Diseases. Retrieved 24 July 2021.
  14. ^ McDowell BD, Wallace RB, Carnahan RM, Chrischilles EA, Lynch CF, Schlechte JA (March 2011). "Demographic differences in incidence for pituitary adenoma". Pituitary. 14 (1): 23–30. doi:10.1007/s11102-010-0253-4. PMC 3652258. PMID 20809113.
  15. ^ Gandhi, Chirag D.; Post, Kalmon D. (2003-01-01). "PrL-Secreting Pituitary Adenomas". {{cite journal}}: Cite journal requires |journal= (help)
  • Adapted from Prolactinoma. U. S. National Institutes of Health Publication No. 02-3924 June 2002. Public Domain Source
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