Hyperprolactinemia is an increase in the level of the hormone prolactin in the blood, most often caused by a pituitary adenoma (prolactinoma). Clinically, this condition is manifested by a violation of the functions of the reproductive system. In women, symptoms include menstrual irregularities, galactorrhea, and infertility. In men, there is a decrease in libido, impotence, gynecomastia. The main diagnostic method is to determine the concentration of serum prolactin. Treatment involves the fight against the cause that caused hyperprolactinemia, the appointment of dopamine receptor agonists. In some cases, there is a need for surgery.
Hyperprolactinemia (persistent galactorrhea-amenorrhea syndrome, hyperprolactinemic hypogonadism) is not an independent disease, but a clinical and laboratory syndrome. The pathology was first described in 1855 by the German gynecologist D. Chiari. The prevalence varies from 1 to 3 people per 1000 population. The condition is more common in women of reproductive age (ratio to men 2.5:1). Prolactinomas account for up to 60% of cases. About 30% of female infertility cases are due to hyperprolactinemia.
There are many reasons why prolactin levels increase. Even some physiological conditions, such as exercise, emotional stress, or sleep, can lead to a transient increase in blood prolactin levels. Frequent physiological causes in women are pregnancy and lactation. Etiological factors of pathological hyperprolactinemia are:
Excessive levels of prolactin in the blood by a negative feedback mechanism suppresses the secretion of GnRH in the hypothalamus, which leads to a decrease in the production of luteinizing and follicle-stimulating hormones. As a result, deficiency of sex hormones, hypoplasia of the external genital organs (hypogonadism), active proliferation of the secretory apparatus of the mammary gland, increased lactogenesis and lactation (galactorrhea), especially in women, develop.
Long-lasting hyperprolactinemia stimulates the processes of bone tissue resorption, which reduces its mineral density (osteoporosis). Leptin resistance, adiponectin deficiency and hypogonadism contribute to the deposition of fat in the subcutaneous fat and increase in serum cholesterol fractions. There is a moderate hyperproduction of androgens by the reticular zone of the adrenal cortex.
By nature, pathological and physiological hyperprolactinemia are distinguished. Separately, macroprolactinemia is distinguished, in which an increased level of a biologically inactive high-molecular fraction of the hormone (big-big prolactin) is observed in the blood. In the latter variant of the condition, there are no clinical symptoms. According to the mechanism of occurrence, hyperprolactinemia is divided into:
Depending on the size, the following types of prolactinomas are distinguished:
In women, in the clinical picture, menstrual cycle disorders such as oligo-, opso- or amenorrhea, anovulation come to the fore. There are symptoms such as anorgasmia, decreased libido, frigidity. If hyperprolactinemia has developed before the onset of puberty, hypoplasia of the uterus, labia minora, and clitoris is noted. Due to relative hyperandrogenism, hirsutism, seborrhea and acne may occur.
The most characteristic and specific symptom of hyperprolactinemia, occurring in 50-70% of women, is galactorrhea (milk secretion from the mammary glands outside the period of feeding a child), which often becomes the first sign of the disease. Its intensity can vary - from the appearance of a few drops of colostrum only during palpation of the mammary gland to spontaneous jet discharge.
Perhaps hidden here are shocking photos of medical operations that show blood and intestines Are you 18 years old? yes no Galactorrhea
In men, the main symptoms are a decrease in libido, erectile dysfunction up to impotence, gynecomastia (enlargement of the mammary glands associated with hypertrophy of the glandular tissue). Galactorrhea is observed in approximately 30-35% of patients. The occurrence of hyperprolactinemia before puberty leads to underdevelopment of the genitals and secondary sexual characteristics (absence or weak growth of mustaches and beards, high timbre of voice).
If hyperprolactinemia is due to prolactinoma, reproductive disorders are accompanied by symptoms associated with the presence of a brain mass. They are usually caused by macroprolactinomas and are therefore more common in men. The most common neurological sign is headache. When the tumor compresses the optic chiasm, ophthalmic disorders join - loss of visual fields, scotomas, bitemporal hemianopsia.
Sometimes there is a symptom such as ophthalmoplegia (paralysis of the muscles of the eye). Germination of prolactinoma in the structures of the diencephalon can provoke neuropsychiatric disorders in the form of emotional lability, sleep disturbance, irritability. Often there are complaints of a non-specific nature - general weakness, increased fatigue, memory impairment.
The main and most common adverse consequence of hyperprolactinemia is primary infertility (up to 70%) associated with ovulatory dysfunction in women and oligo- or azoospermia in men. The stimulating effect of the hormone on the mammary glands provokes the development of mastopathy. Elevated lipid levels accelerate the process of atherosclerosis, which increases the risk of myocardial infarction.
More serious complications are due to the growth of the tumor formation. Prolonged mechanical impact on the chiasm can cause atrophy of the optic nerves and lead to blindness. Due to the compression of neighboring areas of the pituitary gland, other hormonal disorders occur - diabetes insipidus, panhypopituitarism. Rarely, at very large sizes, a prolactinoma compresses the trunk or aqueduct of the brain, grows into the nasal cavity.
The management of patients with hyperprolactinemia is carried out by an endocrinologist or gynecologist. When collecting anamnestic data, they find out which drugs the patient is taking in order to exclude the medicinal nature of the pathology. For women, information about menstruation is specified (frequency of occurrence, profusion, duration). Then an additional examination is prescribed, including:
According to clinical symptoms, the differential diagnosis is primarily carried out with hypogonadotropic hypogonadism - a violation of the synthesis of gonadosteroids due to the pathology of the organs of the reproductive system (ovaries - in women, testicles - in men). A particularly difficult task is the differential diagnosis between non-tumor causes of high serum prolactin levels.
In most cases, the patient is treated on an outpatient basis. Hospitalization is necessary in exceptional situations - for additional examination with an unclear cause of the pathology or preparation for a surgical operation. If hyperprolactinemia is asymptomatic, no therapy is required. Conservative treatment includes the following areas:
Surgical removal of prolactinoma is indicated only in some cases. Among them - resistance to dopamine agonists or their individual intolerance, compression of the optic chiasm by the tumor, causing vision problems. Surgery is also recommended for women with macroprolactinoma who are planning pregnancy. Transsphenoidal adenomectomy is considered the method of choice. The risk of recurrence in macroprolactinomas is very high - up to 80%.
Hyperprolactinemia has a favorable prognosis. Cases of death are extremely rare and only with the malignant nature of the pituitary tumor. The main problem is infertility and visual disturbances (up to complete loss). In the treatment of prolactinoma with dopamine agonists, it is necessary to determine the level of serum prolactin once a month and to conduct an MRI of the pituitary gland annually (for macroprolactinomas, every 6 months).
There is no primary prevention for prolactinomas. If a patient has diseases that can cause an increase in the concentration of prolactin (hypothyroidism, systemic granulomatous diseases), it is recommended to conduct a blood test for this hormone. The study is also performed when prescribing drugs that have hyperprolactinemia in the list of adverse side effects.