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Morning report


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Morning report

  1. 1. Morning Report Heather Shenk 5/28/14
  2. 2. Hyperprolactinemia  Prolactin - secreted by the pituitary lactotroph cells under tonic inhibition by dopamine.  Physiologic causes of hyperprolactinemia include: pregnancy, nipple stimulation, exercise, and food intake.  If modest hyperprolactinemia, exclude pregnancy first and repeat test in a fasting state, with no strenuous exercise before testing.  If no clear secondary or drug-induced cause should be assessed by an imaging study (preferably, MRI of the pituitary gland) to exclude a mass lesion.
  3. 3. Cause Result Pituitary disease Prolactinomas Growth hormone–secreting tumors (cosecretion of prolactin or pituitary stalk effects) Nonfunctioning pituitary tumors (pituitary stalk effects) Lymphocytic hypophysitis (pituitary stalk effects) Empty sella syndrome (pituitary stalk effects) Cushing disease (cosecretion of prolactin or pituitary stalk effects) Nonpituitary sellar and parasellar lesions Craniopharyngioma Hypothalamic disease (sarcoidosis, Langerhans cell histiocytosis, lymphoma) Metastatic tumors to pituitary/hypothalamus Meningiomas Dysgerminomas Irradiation Neurogenic Chest wall or spinal cord disease Breast stimulation/lesions Drugs Psychotropic agents (butyrophenones and phenothiazines, monoamine oxidase inhibitors, TCA, fluoxetine, molindone, risperidone, cocaine) Antihypertensive agents (verapamil, methyldopa, reserpine) Metoclopramide (Estrogen in conventionally used doses does not cause hyperprolactinemia.) Other Pregnancy, Physiologic cause (coitus, nipple stimulation, strenuous exercise, stress), Hypothyroidism, Chronic kidney failure, Cirrhosis, Macroprolactinoma Idiopathic Adrenal insufficiency
  4. 4. Presentation  Symptoms: galactorrhea, oligomenorrhea, amenorrhea, hirsuitism, erectile dysfunction, decrease libido, infertility, headache, osteopenia. Mass effect causing peripheral visual field loss.  Indications for treatment: Estrogen deficiency (pre- menopausal with amenorrhea and oligomenorrhea), infertility, bothersome galactorrhea and hirsuitism. In men, symptomatic testosterone deficiency, reduced libido or gynecomastia. Headaches, mass effect, osteopenia, osteoporosis.
  5. 5. Treatment  Exclude secondary causes  Dopamine agonist – cabergoline, bromocriptine  Decrease serum prolactin and shrink prolactinoma.  Use as first line therapy  Consider withdrawal if normal prolactin level for 2 years and no visible tumor on MRI  In women who do not desire pregnancy, estrogen deficiency may be treated with OCP  Surgerical resection if unresponsive or poorly tolerant of medical therapy.  80% remission for micropolactinoma and 40% for macroprolactinomas
  6. 6. Pregnancy  Dopamine agonists have no increased risk of fetal malformations.  Stop drug after conception – except if history of optic chiasm compression.  Prolactinomas may increase in size in pregnancy and closer monitor is needed – but not by checking prolactin level.
  7. 7. Questions  26-year-old woman is evaluated for hyperprolactinemia after recent follow-up laboratory studies showed a serum prolactin level of 55 ng/mL (55 µg/L). Mild hyperprolactinemia (serum prolactin level of 35 ng/mL [35 µg/L]) was detected 6 years ago during an evaluation for irregular menstrual cycles; an MRI performed at that time showed a pituitary microadenoma. She was treated with a dopamine agonist, and subsequent serum prolactin measurements have shown normal levels until the most recent measurement. The patient underwent menarche at age 13 years and has had irregular menstrual cycles since that time, with multiple missed cycles. She has never been pregnant. Her family history is unremarkable, and she takes no medication.  On physical examination, blood pressure is 108/70 mm Hg, pulse rate is 82/min, and respiration rate is 12/min; BMI is 25. The patient has a normal distribution of body weight. Breast development is normal, but breast tenderness is noted on examination. No galactorrhea, acne, hirsutism, or striae are present.  Laboratory studies confirm a serum prolactin level of 55 ng/mL (55 µg/L) and show a thyroid-stimulating hormone level of 1.2 µU/mL (1.2 mU/L).
  8. 8. Answers  A. Pregnancy test  B. Random serum growth hormone measurement  C. Serum cortisol measurement  D. Visual field testing
  9. 9. Answers  A. Pregnancy test  B. Random serum growth hormone measurement  C. Serum cortisol measurement  D. Visual field testing  Key Point  In a woman with a modestly elevated serum prolactin level, pregnancy must first be excluded as a cause before a diagnosis of hyperprolactinemia is made
  10. 10. Question  33-year-old woman is evaluated for a 5-month history of amenorrhea and a 3-month history of galactorrhea. The patient says her menstrual cycles were normal before onset of amenorrhea. She takes no medication.  On physical examination, vital signs are normal. Visual field findings are normal. Bilateral galactorrhea is noted.  Results of laboratory studies show a serum luteinizing hormone level of 2 mU/mL (2 units/L), a prolactin level of 965 ng/mL (965 µg/L), and a free thyroxine level of 1.1 ng/dL (14 pmol/L). A serum β-human chorionic gonadotropin measurement is normal.  An MRI shows a 1.5-cm sellar mass with suprasellar extension that impinges on the optic chiasm
  11. 11. Answers  Which of the following is the most appropriate initial treatment?  A. Dopamine agonist therapy  B. Oral contraceptive  C. Radiation therapy  D. Transsphenoidal surgical resection
  12. 12. Answers  Which of the following is the most appropriate initial treatment?  A. Dopamine agonist therapy  B. Oral contraceptive  C. Radiation therapy  D. Transsphenoidal surgical resection  Key Point  In a patient with a macroprolactinoma, administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment.  Dopamine agonists normalize prolactin levels, correct amenorrhea and galactorrhea, and decrease tumor size by more than 50% in 80% to 90% of patients. They are used as first-line therapy, unless visual field loss is significant and progressive. Even with mild visual loss, dopamine agonists are