Prolactin-secreting pituitary tumors in amenorrheic women: a comprehensive study

Role of Medical and Surgical Treatment in Management of the Patients With Prolactinoma: A Single-Center Experience

BACKGROUND

Current guidelines recommend dopamine agonists (DA) as the primary therapeutic approach for prolactinomas; however, emerging evidence suggests that surgical intervention can also yield favorable outcomes.

OBJECTIVE

To comprehensively evaluate prolactinoma patients undergoing surgical and medical treatments at our pituitary center.

METHODS

Retrospective review of mMedical records from prolactinoma patients treated between 2015 and 2022 was performedwere retrospectively reviewed. The study focused on treatment outcomes and remission rates while investigating factors influencing the success of both treatment modalities in achieving remission.

RESULTS

A total of 301 prolactinoma patients were included, of whom 199 were women. Among them, 235 were managed medically, while 66 underwent surgical intervention. The overall remission rates of patients treated with medical and surgery were similar at the final examination (Respectively respectively 82.9% and 81.8%, p=0.114). Factors associated with remission in both treatment modalities included female sex, low initial prolactin levels, small adenoma size, and absence of cavernous invasion. Compared to DA treatment, Ssurgical treatment demonstrated a higher rate of drug-free remission compared to DA treatment for microadenomas, and macroadenomas without cavernous invasion. In cases with cavernous invasion, standalone surgical treatment yielded a low rate of drug-free remission (7.7%); however, when combined with DA therapy post-surgery, remission rates increased to 66.7%.

CONCLUSION

Medical treatment with DAs remains the preferred option for macroadenomas with cavernous sinus invasion, and giant adenomas, with surgery reserved for selected cases to address complications. Conversely, surgery emerges as the most effective modality for achieving remission in patients with microadenomas, and macroadenomas confined to the sella. The recommendation of DAs as first-line therapy for all patients has been withdrawn in the current guidelines, and individual treatment approaches based on tumor characteristics are emphasized. Our results support this approach.

Identifying a causal link between prolactin signaling pathways and COVID-19 vaccine-induced menstrual changes

COVID-19 vaccines have been instrumental tools in the fight against SARS-CoV-2 helping to reduce disease severity and mortality. At the same time, just like any other therapeutic, COVID-19 vaccines were associated with adverse events. Women have reported menstrual cycle irregularity after receiving COVID-19 vaccines, and this led to renewed fears concerning COVID-19 vaccines and their effects on fertility. Herein we devised an informatics workflow to explore the causal drivers of menstrual cycle irregularity in response to vaccination with mRNA COVID-19 vaccine BNT162b2. Our methods relied on gene expression analysis in response to vaccination, followed by network biology analysis to derive testable hypotheses regarding the causal links between BNT162b2 and menstrual cycle irregularity. Five high-confidence transcription factors were identified as causal drivers of BNT162b2-induced menstrual irregularity, namely: IRF1, STAT1, RelA (p65 NF-kB subunit), STAT2 and IRF3. Furthermore, some biomarkers of menstrual irregularity, including TNF, IL6R, IL6ST, LIF, BIRC3, FGF2, ARHGDIB, RPS3, RHOU, MIF, were identified as topological genes and predicted as causal drivers of menstrual irregularity. Our network-based mechanism reconstruction results indicated that BNT162b2 exerted biological effects similar to those resulting from prolactin signaling. However, these effects were short-lived and didn't raise concerns about long-term infertility issues. This approach can be applied to interrogate the functional links between drugs/vaccines and other side effects.

Post-operative surveillance for somatotroph, lactotroph and non-functional pituitary adenomas after curative resection: a systematic review

CONTEXT

Pituitary tumors are the third most common brain tumor and yet there is no standardization of the surveillance schedule and assessment modalities after transsphenoidal surgery.

EVIDENCE ACQUISITION

OVID, EMBASE and the Cochrane Library databases were systematically screened from database inception to March 5, 2020. Inclusion and exclusion criteria were designed to capture studies examining detection of pituitary adenoma recurrence in patients 18 years of age and older following surgical resection with curative intent.

EVIDENCE SYNTHESIS

A total of 7936 abstracts were screened, with 812 articles reviewed in full text and 77 meeting inclusion criteria for data extraction. A pooled analysis demonstrated recurrence rates at 1 year, 5 years and 10 years for non-functioning pituitary adenomas (NFPA; N = 3533 participants) were 1%, 17%, and 33%, for prolactin-secreting adenomas (PSPA; N = 1295) were 6%, 21%, and 28%, and for growth-hormone pituitary adenomas (GHPA; N = 1257) were 3%, 8% and 13%, respectively. Rates of recurrence prior to 1 year were 0% for NFPA, 1-2% for PSPA and 0% for GHPA. The mean time to disease recurrence for NFPA, PSPA and GHPA were 4.25, 2.52 and 4.18 years, respectively.

CONCLUSIONS

This comprehensive review of the literature quantified the recurrence rates for commonly observed pituitary adenomas after transsphenoidal surgical resection with curative intent. Our findings suggest that surveillance within 1 year may be of low yield. Further clinical trials and cohort studies investigating cost-effectiveness of surveillance schedules and impact on quality of life of patients under surveillance will provide further insight to optimize follow-up.

Efficacy and Cerebrospinal Fluid Rhinorrhea after Cabergoline Treatment in Patients with Bioactive Macroprolactinoma

Predicting dopamine agonist resistance in patients with macroprolactinoma is essential for clinicians to prevent treatment failure and subsequent complications such as medication-induced cerebrospinal fluid (CSF) rhinorrhea. We evaluated the features of patients with cabergoline resistance and CSF rhinorrhea in patients with prolactinomas with prolactin levels ≥1000 ng/mL. A total of 140 patients who were newly diagnosed with prolactinoma secreting only prolactin ≥1000 ng/mL and treated with cabergoline for the first time were included in this study. Based on the hormonal and radiologic response of the prolactinoma, the patients were divided into responders and non-responders. Non-responders (36/140, 25.8%) included a higher number of patients receiving hormone replacement than responders (responders, n (%) = 12(11.5) vs. non-responders = 13(36.1), p = 0.001). In propensity score matching analysis, patients who developed CSF rhinorrhea presented more frequent hormone deficiency than responders regardless of initial cabergoline dose. Hormone deficiency was associated with a greater odds ratio for the risk of non-responders (adjusted odds ratio = 5.13, 95% CI 1.96-13.46, p = 0.001). Cabergoline was effective in bioactive macroprolactinoma. Furthermore, initial cabergoline dose was not significantly associated with long-term responsiveness and development of CSF rhinorrhea but the hypopituitarism was independently associated with an increased risk of cabergoline resistance and CSF rhinorrhea.

Giant Prolactinoma Presenting With Facial Nerve Palsy and Hemiparesis

Background

Giant prolactinomas are an exceedingly uncommon type of pituitary adenomas that usually occur in men, and cause extremely high prolactin levels and mass-related symptoms. Rarely, patients may experience neurological deficits resembling ischemic events.

Methods

We describe an unusual case of a young man who presented with stroke-like symptoms and was found to have a giant prolactinoma.

Clinical Case

A 25-year-old man presented with left facial droop and gradually progressing upper and lower extremity weakness for evaluation of stroke. He reported recent weight gain and erectile dysfunction. Physical examination revealed left homonymous hemianopsia, left VII nerve palsy, and left hemiparesis. Magnetic resonance imaging of the brain showed an enormous mass in the sella turcica, which invaded the sphenoid sinus and right side of the skull base. Prolactin level was elevated at 13 580 ng/mL, and the testosterone level was low. The patient was started on cabergoline and had marked improvement in his symptoms in a few months. Fifteen months after starting treatment, he has had more than 90% reduction in tumor volume and a 93% reduction in prolactin level.

Conclusion

Giant prolactinomas are uncommon and present with compressive symptoms that can be mistaken for a stroke. Our case is a unique report of a facial nerve palsy and hemiparesis secondary to giant prolactinoma in the absence of stroke or pituitary apoplexy.

An observational study of pregnancy and post-partum outcomes in women with prolactinoma treated with dopamine agonists

BACKGROUND

In women with prolactinoma medical treatment with dopamine agonists (DA) can restore fertility. A number of studies have established the safety of DA during pregnancy and the impact of pregnancy and lactation on remission of prolactinoma. However, the total number of reported cases remains modest and further evidence is needed.

AIMS

To evaluate the safety of DA during pregnancy and remission of prolactinoma after pregnancy and lactation.

MATERIALS AND METHODS

Retrospective cohort study (2002-2014) of 57 pregnancies in 47 women with prolactinoma who received DA. Neonatal and pregnancy complications were recorded. Prolactin levels and treatment data were collected at the time of diagnosis, pre-conception, during pregnancy and lactation, and post-partum (up to 114 months).

RESULTS

DA treatment was stopped a median of 4.5 weeks after conception in 49 pregnancies (86%). There were 49 live births (86% of pregnancies) and six miscarriages. Six pregnancies had an adverse neonatal outcome including two with congenital malformations. Following 26% of pregnancies women achieved remission after birth or lactation, and 25% of women were in remission at last follow-up. Remission was associated with older maternal age (P = 0.036), a lower prolactin level at diagnosis (P = 0.037), and a smaller adenoma at diagnosis (P = 0.045).

CONCLUSIONS

Successful pregnancy and lactation is common after DA treatment for prolactinoma. Fetal exposure in the first four weeks of pregnancy appears to be generally safe. Encouragingly, post-partum and after lactation a quarter of women had a normal prolactin level without medical treatment.

John C. Vangilder (1935-2007): Neurosurgical Leader and Founder of the Department of Neurosurgery at the University of Iowa

John C. VanGilder, the former professor and chairman of neurosurgery at The University of Iowa died on August 27, 2007 after making a lasting impact to the field of neurosurgery both in the United States and abroad. In this manuscript, we review VanGilder's life and achievements. VanGilder was born in 1935 in West Virginia and received his undergraduate education at West Virginia University in Morgantown. He studied medicine at the University of West Virginia, completing his final 2 years at the University of Pittsburgh, and after serving in the U.S. military, completed his neurosurgical training at Washington University in St. Louis. He was appointed to faculty positions first at Yale University and later at The University of Iowa, where he became professor and later chairman of the Division of Neurosurgery. VanGilder also served as president of the Society of Neurological Surgeons (1997-1998), president of the Neurosurgical Society of America (1998-1999), chairman of the American Board of Neurological Surgery (1997-1998), and vice president of the American Academy of Neurological Surgery. At The University of Iowa, VanGilder played a key role in the transition of the Division of Neurosurgery to a Department of Neurosurgery and mentored several neurosurgeons who would go on to become department chairmen or make other important neurosurgical contributions at other medical schools in the United States.

Hypothalamic-Pituitary-Ovarian Axis Reactivation by Kisspeptin-10 in Hyperprolactinemic Women With Chronic Amenorrhea

Context:

Hyperprolactinemia-induced hypogonadotropic amenorrhea (hPRL-HA) is a major cause of hypothalamic gonadotrophin-releasing hormone (GnRH) deficiency in women. In hyperprolactinemic mice, we previously demonstrated that hypothalamic kisspeptin (Kp) expression was diminished and that Kp administration restored hypothalamic GnRH release, gonadotropin secretion, and ovarian cyclicity, suggesting that Kp neurons could also play a role in hPRL-HA.

Objective:

To study the effect of Kp-10 on the gonadotropic-ovarian axis in women with hPRL-HA.

Patients:

Two women (32 and 36 years old) with chronic hPRL-HA (prolactin: between 94 and 102 and 98 and 112 ng/mL, respectively) caused by cabergoline-resistant microprolactinomas.

Interventions:

Cabergoline was discontinued 6 months before inclusion. Blood samples were taken every 10 minutes for 12 hours during 2 consecutive days to evaluate luteinizing hormone (LH) and follicle-stimulating hormone (FSH) secretion. Serum estradiol (E2), testosterone (T), and inhibin B (IB) levels were also measured. Vehicle or Kp-10 (1.5 μg/kg/h) was infused intravenously for 12 hours.

Results:

Kp-10 induced a significant increase in LH and FSH levels and increased LH pulses. E2, T, and IB serum levels were also significantly increased.

Conclusions:

In this exploratory study, we demonstrated that administration of Kp-10 reactivated gonadotropin secretion in women with hPRL-HA and increased ovarian activity. Our data suggest that, as in rodents, GnRH deficiency in hPRL-HA is also mediated by an impairment of hypothalamic Kp secretion. Kp-10 or its analogues could have therapeutic application as an alternative approach to restore ovarian function and fertility in women with hPRL-HA resistant to dopamine agonists and in whom pituitary surgery is not possible.

Serotonin and Antidepressant SSRIs Inhibit Rat Neuroendocrine Dopamine Neurons: Parallel Actions in the Lactotrophic Axis

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for depression, but sexual side effects often compromise compliance. These reproductive dysfunctions are likely mediated by elevations of the hormone prolactin. Yet, how serotonin (5-HT) and SSRIs cause changes in prolactin secretion is not known. Here, using in vitro whole-cell patch-clamp recordings, we show that 5-HT hyperpolarizes and abolishes phasic discharge in rat neuroendocrine tuberoinfundibular dopamine (TIDA) neurons, the main inhibitor of prolactin secretion. This process is underpinned by 5-HT1A receptor-mediated activation of G-protein-coupled inwardly rectifying K(+)-like currents. We further demonstrate that the SSRIs, fluoxetine and sertraline, directly suppress TIDA neuron activity through parallel effects, independent of 5-HT transmission. This inhibition involves decreased intrinsic excitability and a slowing of TIDA network rhythms. These findings indicate that SSRIs may inhibit neuroendocrine dopamine release through both 5-HT-dependent and -independent actions, providing a mechanistic explanation for, and potential molecular targets for the amelioration of, the hyperprolactinemia and sexual dysfunction associated with these drugs.

SIGNIFICANCE STATEMENT

Depression affects approximately one-tenth of the population and is commonly treated with selective serotonin reuptake inhibitors (SSRIs; e.g., Prozac). Yet, many patients withdraw from SSRI therapy due to sexual side effects (e.g., infertility, menstrual disturbances, and impotence). Although it is generally accepted that sexual side effects are due to the ability of these drugs to elevate blood levels of the hormone prolactin, the mechanism for this hormonal imbalance is not known. Here, we show that SSRIs can inhibit hypothalamic dopamine neurons that normally suppress the secretion of prolactin. Intriguingly this inhibition can be explained both by increased serotonin activity and also by parallel serotonin-independent actions.

Menstrual Cycle Abnormalities in Patients with Prolactinoma and Drug-induced Hyperprolactinemia

BACKGROUND AND OBJECTIVE

Hyperprolactinemia affects the reproductive endocrine axis; however, the degree of dysfunction may vary depending on etiology. The aim of the present study was to analyze menstrual cyclicity in patients with prolactinoma and drug-induced hyperprolactinemia (DIH).

METHODOLOGY

Patients with prolactinoma and DIH were retrospectively analyzed for menstrual cyclicity at presentation and response to therapy.

RESULTS

Of 128 females with hyperprolactinemia, 58 had prolactinoma (41 microadenoma and 17 macroadenoma) and 39 had DIH. Patients with prolactinoma had higher prolactin levels and increased frequency of oligomenorrhea (77.5% vs. 46%) as compared to DIH. Patients with macroprolactinoma had more severe menstrual disturbances compared to microprolactinoma. A higher percentage of patients with microprolactinoma and DIH achieved regular menstrual cycles compared to macroprolactinoma postcabergoline treatment (85% and 90% vs. 65%). There was no correlation between time to regularization of menstrual cycles with age, menstrual cycle length, duration of menstrual irregularity, or initial prolactin level in patients with prolactinoma. Linear regression analysis showed a significant association between time to regularization of menstrual cycles with time to normalization of prolactin levels (P = 0.001).

CONCLUSION

There is a prompt restoration of menstrual cycles in patients with microprolactinoma and DIH. Patients with macroprolactinoma have more severe menstrual disturbances and lesser frequency of cycle restoration postcabergoline treatment compared to microprolactinoma and DIH.

Lesson of the month (1): cabergoline - 'i eat funny on that'

We present the case of a patient treated for hyperprolactinaemia with weekly doses of cabergoline for 12 years. Over this time she had suffered from binge eating and compulsive shopping which impacted on her weight and made her finances precarious. We discuss the features of impulse control disorders and suggest that seeking out these side effects in patients taking such agents is important. The behaviours may be embarrassing and patients may not volunteer them, likewise if the doctor dismisses them they may continue unabated, causing significant social harm.

Giant prolactinoma: case report and review of literature

“Invasive giant prolactinoma” is a large prolactinoma (>4 cm in dimension) presenting with serum prolactin levels of >1000 ng/dL and mass related clinical symptoms. Here we report a patient with a giant prolactinoma presented with central hypogonadism, suppressed adrenal and thyroid function, supra sellar extension, visual field impairment and high prolactin level.

The patient was treated with cabergoline, levothyroxin and prednisolone. After 18 months, tumor size markedly reduced, associated with adrenal function and visual field improvement, but central hypogonadism and secondary hypothyroidism persisted.

Previous studies showed normalization of thyrotropin secretion after treatment but it remained low in our patient even after 18 months follow up.

Hyperprolactinaemia

Hyperprolactinaemia is a frequent cause of reproductive problems encountered in clinical practice. A variety of pathophysiological conditions can lead to hyperprolactinaemia; therefore, pregnancy, drug effects, hypothyroidism and polycystic ovary syndrome should be excluded before investigating for prolactin-secreting pituitary tumours. Prolactinomas are mainly diagnosed in women aged 20-40 years. They present with clinical features of hyperprolactinaemia (galactorrhoea, gonadal dysfunction), and more rarely with large tumours, headache and visual field loss due to optic chiasm compression. Medical therapy with dopamine agonists is the treatment of choice for both micro- and macroprolactinomas. Tumour shrinkage and restoration of gonadal function are achieved in the majority of cases with dopamine agonists. A trial of withdrawal of medical therapy may be considered in many patients with close follow-up. Pituitary surgery and radiotherapy currently have very limited indications. Pregnancies in patients with prolactinomas need careful planning and close monitoring.

Incidence and clinical significance of elevated macroprolactin levels in patients with hyperprolactinemia

OBJECTIVE

To determine the prevalence and clinical characteristics of patients with macroprolactinemia in an endocrinology practice at a tertiary care military medical center in the United States.

METHODS

We reviewed the medical records of 40 patients who had been referred for evaluation of hyper-prolactinemia between June 2003 and August 2004 in whom macroprolactin had been measured.

RESULTS

Of the 40 patients, 18 (9 men and 9 women) (45%) had an elevated macroprolactin level (mean, 75% of the total prolactin). The demographic characteristics of these patients were similar to those of patients with elevated monomeric prolactin. Most of the men with macro-prolactinemia (78%) had erectile dysfunction as the presenting complaint, whereas the most frequent symptom in women was menstrual irregularities (56%). Fifty percent of patients had no identifiable cause for their presenting complaint other than macroprolactinemia. Of the 18 patients with macroprolactinemia, 16 underwent magnetic resonance imaging (MRI) of the pituitary, of whom 56% had normal findings. Of the patients with abnormal MRI findings, 57% had a microadenoma, and 43% had either an atrophic anterior lobe or a prominent hypophysis. No significant relationship was detected between MRI findings or symptoms and the presence of elevated macroprolactin levels. Approximately 40% of patients in the macroprolactin group were treated with a dopamine agonist, 28% of whom had normalization of the total prolactin level.

CONCLUSION

Although macroprolactin is commonly found in patients with hyperprolactinemia, neither symptoms nor MRI findings are useful in predicting its presence. Patients with macroprolactinemia often have symptoms similar to those in patients with elevation in monomeric prolactin. The clinical significance of macro-prolactinemia remains uncertain.

Development of a macroprolactinoma in association with hormone replacement therapy in a perimenopausal woman with presumed idiopathic hyperprolactinemia

OBJECTIVE

To describe a 48-year-old woman with presumed idiopathic hyperprolactinemia, who was found to have a macroprolactinoma after receiving hormone replacement therapy for almost 3 years.

METHODS

We present a detailed case report, including a chronologic summary of clinical and laboratory findings as well as the drug history of our patient. The related literature is also reviewed.

RESULTS

Premenopausal women with idiopathic hyperprolactinemia or microprolactinomas (<1 cm) are treated with dopamine agonists if fertility is desired or galactorrhea is bothersome. Otherwise, estrogens and progestational agents may be prescribed to regularize menses and prevent osteoporosis. Several case reports of prolactinoma formation or enlargement after exposure to exogenous estrogens have been published. In our patient, a perimenopausal woman with presumably idiopathic long-standing hyperprolactinemia, a macroprolactinoma developed within 3 years after initiation of hormone replacement therapy for management of perimenopausal symptoms. The only clue for ordering a pituitary imaging study in this case was a substantial increase in the level of the serum prolactin. Treatment with cabergoline normalized the patient's serum prolactin level and considerably decreased the size of her pituitary adenoma.

CONCLUSION

It is postulated that exogenous estrogens could have an important role in tumor development or growth in some patients with idiopathic hyperprolactinemia. Therefore, it is recommended that women with idiopathic hyperprolactinemia or microprolactinomas treated with estrogens be considered for concomitant therapy with dopamine agonists. In all cases, serum prolactin levels should be diligently monitored.

Hyperprolactinaemia in 271 women: up to three decades of clinical follow-up

OBJECTIVE

To characterize women with hyperprolactinaemia at diagnosis and to assess the effect of treatment after long duration of the disease.

DESIGN

Retrospective chart review.

PATIENTS AND MEASUREMENTS

Two hundred and seventy-one women with hyperprolactinaemia at the Karolinska University Hospital, Stockholm, Sweden between 1974 and 2002 were evaluated retrospectively. Criterion for inclusion was elevated S-PRL (> or = 20 microg/l) found on at least two occasions. Secondary hyperprolactinaemia was excluded. The patients were followed for a median time period of 111 (6-348) months. Two hundred and forty patients were treated with dopamine agonists, 17 underwent surgery, seven received radiotherapy and seven were followed without treatment.

RESULTS

Mean age at diagnosis was 31 (+/- 9.5) years and median PRL level was 72 (25-3500) microg/l. Menstrual disturbances were present in 87% of the women of reproductive age and 47% had galactorrhoea. Microadenomas were found in 63%, macroadenomas in 8% and idiopathic hyperprolactinaemia in 29%. Patients with menstrual disturbances had higher PRL levels than women with normal menstrual function (P < 0.001). We found no differences in PRL levels between patients with or without galactorrhoea (P = 0.578). At the end of clinical follow-up, menstrual cycle was normalized in 94% and galactorrhoea disappeared in 94%. In the medically treated patients, median PRL levels decreased from 70 (25-3100) to 13 (0-89) microg/l, (P < 0.0001). Normalization of PRL level was achieved in 71% of the patients and 80% showed a total or partial degree of tumour shrinkage. In the surgically treated patients, 53% had normal PRL levels without medication at follow-up.

CONCLUSION

Medical treatment was effective in correcting hypogonadism, normalizing PRL levels and reducing tumour size in the majority of the patients after short-term treatment and also in the long run. However, the possibility of transsphenoidal surgery in specific cases must be considered.

Contemporary management of prolactinomas

Prolactin-secreting pituitary adenomas--prolactinomas--are the most common type of functional pituitary tumor. Treatment of hyperprolactinemia is indicated because of the consequences of infertility, gonadal dysfunction, and osteoporosis. Making the correct diagnosis is important because the first line of therapy is medical management with dopamine agonists. Medical therapy is effective in normalizing prolactin levels in more than 90% of patients, but longterm treatment may be required in some patients. Transsphenoidal surgery is usually indicated in those patients in whom medical therapy fails or cannot be tolerated, or in patients who harbor microprolactinomas. In experienced hands, a hormonal and oncological cure can be achieved in more than 90% of patients after transsphenoidal removal of microprolactinomas with minimal risks. Thus, surgery may be an option for microprolactinomas in a young patient who desires restoration of fertility and avoidance of long-term medical therapy. The authors review the diagnosis and management of prolactinomas, including medical therapy, surgical therapy, and stereotactic radiosurgery.

Giant prolactinomas: clinical management and long-term follow up

OBJECT

Giant prolactinomas are rare tumors whose treatment and outcome has only been addressed in isolated case reports. The authors document the long-term follow-up findings and clinical outcome in a group of patients with giant prolactinomas.

METHODS

This study is a retrospective chart and clinical review of more than 2000 cases of pituitary tumors treated at the authors' institution, of which 10 met the criteria for inclusion (prolactin level > 1000 ng/ml, diameter > 4 cm on neuroimaging studies, and clinical signs of hyperprolactinemia/mass effect). The average follow-up duration was 6.7 years after initial treatment with either bromocriptine or transsphenoidal resection. In more than 90% of the patients in this series the disease was controlled by medical treatment with bromocriptine alone; the other 10% required early surgery via transsphenoidal resection. All patients had improvement in visual symptoms. All tumors had extrasellar components, five of which exhibited frank invasion of the cavernous sinus. Tumor volume on magnetic resonance imaging was decreased on average by 69%; this occurred at a faster rate and in larger amounts when treated with bromocriptine than has been reported in the literature for macroprolactinomas.

CONCLUSIONS

According to long-term follow-up findings, giant prolactinomas are exquisitely responsive to dopamine agonist therapy. In giant prolactinomas the prolactin level does not correlate with size. The main indication for early surgery is intratumoral hematoma, whereas our main indications for late surgery are cerebrospinal fluid leakage caused by medical treatment, or an increasing prolactin level despite medical therapy. Checking prolactin levels in suspicious sellar and/or suprasellar lesions may be diagnostic and prevent unnecessary surgery.

Atypical polypoid adenomyoma in a patient with hyperprolactinemia

We report a case of an atypical polypoid adenomyoma in a patient with hyperprolactinemia. A 23-year-old Japanese woman was admitted complaining of atypical genital bleeding. Specula examination revealed a walnut-size polypoid mass extruding from the cervix. The patient was oligomenorrheac, and endocrine analysis showed hyperprolactinemia. Transvaginal ultrasonography and magnetic resonance imaging revealed an endometrial polypoid mass (4 x 3 x 3 cm) arising from the lower segment of the uterine corpus. The pathologic diagnosis of the tumor after polypectomy was atypical polypoid adenomyoma. It is suggested that ovarian dysfunction caused by hyperprolactinemia may be involved in the pathogenesis of atypical polypoid adenomyoma in the present case.

Long-term follow-up of 246 hyperprolactinemic patients

BACKGROUND

We wanted to evaluate the very long-term effects of bromocriptine on prolactin (PRL) levels and pituitary tumor size in a large cohort of hyperprolactinemic patients.

METHODS

We conducted a retrospective cohort study in the Department of Endocrinology from Necker Hospital in Paris, France. Two hundred and forty-six patients consulted primarily for menstrual disorders, with diagnosis of hyperprolactinemia. Patients were followed-up for 99.9+/-3.6 months. One hundred and ninety-one were treated with bromocriptine, 32 underwent surgery, and 23 received no treatment.

RESULTS

The mean initial plasma PRL level was 135.0+/-20.2 ng/ml. Presence of an adenoma was detected in 60% of our patients and comprised a microadenoma in 64% of cases. Compared to oligomenorrheic women, amenorrheic patients had significantly higher levels of PRL and larger pituitary tumor size. In the bromocriptine group, PRL levels decreased from 99.6+/-7.9 to 20.0+/-1.5 ng/ml (p=0.00001). The medical treatment was associated with disappearance of the adenoma in 45% of the women and with stabilization of pituitary tumor size in 40% of patients. Surgery led to disappearance of the adenoma in almost all cases, but failed to definitively cure hyperprolactinemia.

CONCLUSION

In this large-scale retrospective study, the medical treatment of mild hyperprolactinemia was shown to be effective and sufficient after 9 years of follow-up.

Pituitary surgery

Surgical management of pituitary adenomas continues to be a safe and effective method for treating many patients with these lesions. The goal of overall management should be to provide the patient with the most effective means of long-term control of this benign but potentially disabling disease. Currently, surgery has a significant role. It is hoped that with advances in the understanding of pituitary pathophysiology and with advances in pharmacotherapy, surgical management may become even more focused, more precise, and more effective over time.

Transsphenoidal microsurgical therapy of prolactinomas: initial outcomes and long-term results

OBJECTIVE

Prolactinomas are frequently treated primarily with dopamine agonists; however, these agents have disadvantages and require life-long therapy. We therefore reassessed transsphenoidal microsurgery as an alternative therapy.

METHODS

We reviewed the data for 121 female patients treated surgically for prolactinomas between 1976 and 1979 (Group 1) and 98 patients treated between 1988 and 1992 (Group 2).

RESULTS

Of 219 women, 92% with preoperative prolactin (PRL) values of < or = 100 ng/ml and 91% with intrasellar microadenomas experienced initial remission; 80 to 88% of patients with intrasellar macroadenomas or macroadenomas showing moderate suprasellar extension or focal sphenoid sinus invasion experienced remission. Women with PRL values of > 200 ng/ml and those with larger and more invasive adenomas experienced poorer outcomes (37-41% remission). Lower preoperative PRL values and adenoma stage were the best predictors of initial surgical outcomes. At the most recent evaluations, 89% of women who experienced initial remission continued to experience clinical remission; 85% exhibited normal PRL values, and 5% demonstrated mild, asymptomatic, recurrent hyperprolactinemia (PRL values of < 34 ng/ml). In Group 1, 84% of patients continued to experience remission (82% with normal PRL values) after a median follow-up period of 15.6 years. In Group 2, 97% of patients continued to experience remission (88% with normal PRL values) after a median follow-up period of 3.2 years. Lower postoperative PRL values were the best predictors of long-term remission.

CONCLUSION

Transsphenoidal microsurgery is an effective alternative to long-term medical therapy for selected patients with prolactinomas. Successful outcomes and long-term remission were achieved in patients with microadenomas and noninvasive macroadenomas.

Prolactinomas in male and female patients: a comparative clinicopathologic study

OBJECTIVE

To explore the basis of the gender-based differences in endocrine and surgical findings in patients with prolactinoma (prolactin cell adenoma) as well as in their clinical outcome.

MATERIAL AND METHODS

In young or reproductive-age female patients, older women (beyond 40 years of age), and male patients, we systematically studied the following factors: operative and endocrine features (tumor size, invasiveness, preoperative serum prolactin level, and biochemical outcome), specific biologic variables (mitotic index, MIB-1 labeling index, and p27 immunoreactivity), and hormone receptor status (estrogen and progesterone receptor proteins as well as dopamine D2 receptor messenger RNA).

RESULTS

Of the various factors assessed, the preoperative prolactin level and MIB-1 labeling index were lower in young female patients in comparison with older female and particularly male patients. Hormone levels were also positively associated with mitotic activity as well as the MIB-1 labeling index. Although invasion was infrequent in microadenomas of young female patients, no statistically significant differences in tumor size or invasiveness were noted among the three patient groups. Absence of differences in invasiveness may, in part, be explained by artifacts of case selection.

CONCLUSION

The basis for the observed differences in proliferative activities in tumors of the three study groups is not readily apparent but may reflect differences in the endocrine milieu or the effect of sex steroid hormone receptors, tumoral vascularity, or specific growth factors.

Prolactin disorders

OBJECTIVE

To review the pathophysiology, clinical manifestations, current diagnostic procedures, and treatment options for disorders involving PRL production. Common clinical dilemmas are discussed in a pragmatic fashion to guide the practitioner.

DESIGN

A world literature search of basic sciences and medical articles from the last three decades was performed using computerized MEDLINE. Recent endocrine and reproductive endocrine textbooks also were reviewed. Studies were selected for their degree of contribution to the basic sciences and clinical understanding of the disorder and for the quality of their study design and content. The information was summarized and grouped according to its relevance and application to specific sections of the manuscript. Studies were evaluated and critically used to support the views of the authors and to suggest specific clinical management strategies.

RESULT(S)

Disorders derived from abnormal PRL production are relatively common in clinical practice. Infertility, menstrual disorders, and galactorrhea are the most frequent manifestations encountered in women. Although frequently benign, the disorder occasionally may have severe consequences.

CONCLUSION(S)

An understanding of the underlying physiology and pathophysiology coupled with the awareness of the heterogeneous presentation of this disorder should help the clinician to approach it successfully.

Diagnosis and drug therapy of prolactinoma

A prolactin-secreting pituitary tumour is the most frequent cause of hyperprolactinaemia that commonly occurs in clinical practice. Prolactinomas occur more frequently in women than in men and may differ in size, invasive growth and secretory activity. At presentation, macroadenomas are more frequently diagnosed in men. Specific immunohistochemical stains are necessary to prove the presence of prolactin in the tumour cells. The main investigations in the diagnosis of a prolactin-secreting adenoma are hormonal and radiological. As prolactin is a pulsatile hormone, it is a general rule to obtain several blood samples by taking a single sample on 3 separate days or 3 sequential samples (every 30 minutes) in restful conditions. Prolactin levels of 100 to 200 micrograms/L are commonly considered diagnostic for the presence of a prolactinoma; however, prolactinoma cannot be excluded in the presence of lower levels, and prolactin levels > 100 micrograms/L are present in some patients with idiopathic hyperprolactinaemia. Several dynamic function tests have been proposed to differentiate idiopathic from tumorous hyperprolactinaemia. Although they could be used for group discrimination, these tests cannot be used for individual patients. To differentiate between a prolactinoma and a pseudoprolactinoma, thyrotrophin response to a dopamine receptor antagonist may be used, as only prolactinomas may have an increased response. A short course of dopaminergic drugs may also be of some help, as in macroprolactinomas only a shrinkage may be observed. After hyperprolactinaemia is confirmed, imaging with computerised tomography (CT) and magnetic resonance imaging (MRI) are necessary to define the presence of a lesion compatible with a pituitary tumour. There is now a general agreement that medical therapy is of first choice in patients with prolactinomas. Bromocriptine, the most common drug used in this condition, is a semisynthetic ergot alkaloid that directly stimulates specific pituitary cell membrane dopamine D2 receptors and inhibits prolactin synthesis and secretion. In most patients, a reduction or normalisation of prolactin levels is usually observed, together with the disappearance or improvement of clinical symptoms. The sensitivity to bromocriptine is variable and patients may need different dose of the drug. Bromocriptine is also able to shrink the tumour in most patients; however, a few reports of disease progression during therapy have been described. The need for close follow-up, including prolactin levels and CT or MRI studies, is therefore emphasised. Bromocriptine is conventionally given in 2 or 3 daily doses; however, a single evening dose has been shown to be equally effective. Bromocriptine is usually well tolerated by the majority of patients; some adverse effects (nausea, vomiting, postural hypotension) may be initially present, but they usually wear off in time. To prevent such adverse effects it is advisable to start treatment with a low dose during the evening meal and gradually increase the dose over days or weeks. A few patients are unable to tolerate oral bromocriptine, so different formulations of bromocriptine or alternative dopamine agonist drugs (lisuride, terguride, metergoline, dihydroergocryptine, quinagolide, cabergoline, pergolide) have been proposed. Of particular clinical relevance because of their good tolerability and sustained activity are cabergoline and quinagolide. Particular attention should be paid to pregnancy in prolactinoma patients, as tumour enlargement has been reported. As the risk for this occurrence is low in patients with microprolactinoma, there is a general agreement that the drug can be stopped once pregnancy is diagnosed. In patients with macroprolactinoma the risk of tumour enlargement is higher. Therefore, primary therapy with bromocriptine until the tumour has shrank is suggested before pregnancy is attempted. Bromocriptine should be stopped as soon as pregnancy is confirmed, but re

Clinical impact of hyperprolactinaemia

Prolactinomas are benign, functioning pituitary tumours that cause reproductive dysfunction in men and women. PRL-secreting microadenomas have a benign clinical course and may even disappear without treatment. Absolute indications for treatment of hyperprolactinaemia include the need to restore fertility and the presence of a macroadenoma. A dopamine agonist is the treatment of choice regardless of tumour size and will normalize PRL and restore menses in the majority of cases. Hypogonadism induced by hyperprolactinaemia is associated with decreased spinal bone mineral content, but it is not clear whether the bone loss is progressive. Bone mass improves after treatment of the hyperprolactinaemia but does not normalize. The safety of chronic oestrogen therapy in women with hyperprolactinaemic amenorrhoea who are not desirous of fertility remains to be elucidated by ongoing clinical trials.

Rapid modulation of ovarian 3 beta-hydroxysteroid dehydrogenase/delta 5-delta 4 isomerase gene expression by prolactin and human chorionic gonadotropin in the hypophysectomized rat

In order to better understand the role of prolactin (PRL) and luteinizing hormone (LH) on progesterone biosynthesis in the ovary, we have investigated the time course (1-9 days) of the effect of PRL and human chorionic gonadotropin (hCG) on ovarian 3 beta-hydroxysteroid dehydrogenase/delta 5-delta 4 isomerase (3 beta-HSD) expression in the hypophysectomized rat. As evaluated by quantitative in situ hybridization using a 35S labelled type I 3 beta-HSD cDNA probe, the administration of hCG for 2, 3 and 9 days induced increases of 63%, 145% and 146% above control, respectively, in 3 beta-HSD mRNA levels in ovarian interstitial cells. The absence of apparent effect of the gonadotropin in other ovarian cell types could explain the small modulation of ovarian 3 beta-HSD protein content and enzymatic activity observed in total ovarian tissue. On the other hand, treatment with PRL caused a rapid decrease in 3 beta-HSD mRNA levels in corpus luteum by 23%, 63%, 76% and 78% (P < 0.01) following 1, 2, 5 and 9 days of treatment, respectively. The short-term inhibitory effect of PRL was also observed on ovarian immunoreactive 3 beta-HSD protein, as measured by Western blot analysis, and on 3 beta-HSD activity measured by the conversion of [14C]dehydroepiandrosterone into [14C]androstenedione.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperprolactinemia enhances LH-stimulated 4-ene-5 alpha-reductase activity but inhibits LH-induced 17-hydroxylase activity in testes of hypophysectomized immature rats

Two pituitaries from 7-week old female rats (Sprague-Dawley strain) were grafted under the capsule of the left kidney of 21-day old male rat. The pituitary grafted and sham-operated rats were hypophysectomized at 27 days of age. The hypophysectomized rats, in groups of 4, were given daily injections of 9 micrograms NIAMDD-oLH-23 (minimum effective dose) or saline for 3 days starting from day 29. Testicular homogenates were incubated with [3H]progesterone or [14C]4-androstene-3,17-dione, and enzyme activities per testes were estimated. Testicular HCG-binding sites were also measured. Hypophysectomy caused significant decreases in activities of testicular 5 alpha-reductase, 17-hydroxylase, and 17 beta-hydroxysteroid oxidoreductase. These decreased enzyme activities were significantly stimulated by LH treatment. Although pituitary grafts alone showed no effects on these enzyme activities in the testes of the hypophysectomized rats, the grafts significantly enhanced LH-stimulated 5 alpha-reductase activities but inhibited LH-stimulated 17-hydroxylase activity. Testicular LH/HCG receptors were significantly increased by the grafts, especially in the presence of LH, without affecting affinity for HCG. The present results demonstrate for the first time that hyperprolactinemia directly stimulates LH-stimulated 5 alpha-reductase activity in rat testes. The results also show that the same grafts directly inhibit LH-stimulated 17-hydroxylase activity, probably via postreceptor mechanisms.

Diagnosis and management of prolactinomas

Prolactin secreting tumors account for ten to twenty percent of all intracranial lesions. The patients harboring these tumors present with amenorrhea, galactorrhea, other ovulatory disorders, infertility, delays in puberty and mixed polyendocrinopathy. These tumors are diagnosed by the measurement of serum prolactin levels, Goldmann-Bowl perimetry, and either computed axial tomography or magnetic resonance imaging. Protein secreting tumors are usually benign lesions and historically have been treated by partial or total hypophysectomy or radiation therapy. Surgical resection of the lesion often is followed by recurrence and administration of proton beam radiation therapy results in the development of a panhypopituitary state. Growth of pituitary tumors is controlled with the administration of dopamine agonists such as bromocriptine and prospective studies have suggested that these drugs are now the preferred method of treatment for primary lesions and recurrences.

The effects of prolactin on rat ovarian function

Hyperprolactinemia has been associated with several reproductive disorders. To investigate whether hyperprolactinemia directly affects rat ovarian function, we examined the ovarian histopathology and the activities of the four ovarian enzymes 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), 17-hydroxylase (17-OH), 17,20-desmolase (17,20-D) and aromatase in hyperprolactinemic rats and controls. Hypophysectomized, gonadotropin-treated Fisher rats were made hyperprolactinemic by isografting pituitary glands under the kidney capsule. The control animals received skeletal muscle. The ovaries were resected, pooled according to prolactin levels and microsomal enzyme activities were measured from each pool. Prolactin (PRL) levels were 344 +/- 23 ng/ml in the hyperprolactinemic rats and 18 +/- 5 ng/ml in the controls (p less than 0.001). Estradiol concentrations were 609 +/- 47 pg/ml in the hyperprolactinemic animals and 56 +/- 13 pg/ml in the controls (p less than 0.001). Ovarian and uterine weights were significantly higher in the hyperprolactinemic rats (p less than 0.02). Ovarian histopathology demonstrated benign polycystic transformation in the hyperprolactinemic animals. Hyperprolactinemia had no effect on 3 beta-HSD, but was associated with significant decreases in the 17-OH, 17,20-D and aromatase activities when compared to controls (p less than 0.001). We conclude that prolactin has a direct effect on rat ovarian function which appears to be independent of changes in gonadotropin secretion.

Comparative effects of tamoxifen and bromocriptine on prolactin and pituitary weight in estradiol-treated male rats

Male ACI rats were treated with estradiol to induce hyperprolactinemia and pituitary hypertrophy and hyperplasia. Animals received estradiol alone or with tamoxifen or bromocriptine for 4, 8, or 12 weeks. Estradiol treatment resulted in time-dependent increases in pituitary wet weight and serum prolactin concentrations. Tamoxifen completely blocked the increase in both variables; bromocriptine decreased but did not prevent time-dependent increases. Animals were also treated for 8 weeks with estradiol alone, followed by 4 weeks with estradiol and tamoxifen or bromocriptine. Neither compound reversed the hyperprolactinemia, although the pituitary wet weight of animals treated with bromocriptine was slightly but significantly reduced. These findings suggest that in this model if treatment is initiated simultaneously with estrogen stimulation, tamoxifen is more effective than bromocriptine at the doses studied; and, if therapy is initiated subsequent to the establishment of estrogen-induced hyperprolactinemia and pituitary hyperplasia, bromocriptine is more effective than tamoxifen at the doses studied.

Galactorrhea in the adolescent

Inappropriate lactation--that which occurs beyond the usual postpartum or breast-feeding period or in the male--has been of medical interest for centuries. There is a suggestion that the first recorded case occurred in the Bible in the Book of Esther wherein Mordecai may have breast-fed his niece Esther [1,2]. The Talmud describes a man who nursed his infant after his wife's death during childbirth [3]. Lactation in virgin women was noted by the early Greeks [4], and Aristotle observed lactation in men [5]. The phenomenon of "witch's milk," seen in the newborn, was described as early as 1684 by Bonetus [6]. The first alleged pediatric case of nonpuerperal lactation was of an 8-year-old girl who was able to suckle her baby brother as reported in the 18th Century by Baudelocque [7]. Subsequently, many other cases of abnormal lactation were described in the 19th and early 20th centuries [7-10]. In the past 15 years, there has been a vast proliferation of cases and studies concerning galactorrhea of both sexes [11]. The advent of the prolactin radioimmunoassay was the single most important factor behind the profusion of these investigations [11-14]. Most recently, attention has focused on the high incidence of pituitary tumors--specifically the prolactinoma--in women and to some degree in men [13,15]. The occurrence of such tumors in children and adolescents is also receiving more attention [16,17]. The purpose of this review is to update the reader on galactorrhea with a specific emphasis on: 1) outlining the various causes of galactorrhea that may be seen in adolescent patients; 2) describing the work-up and management of both the male and female adolescent patient with galactorrhea; and 3) describing what is known about the natural history of galactorrhea. A brief description of the physiology of the hypothalamic-pituitary-breast axis and lactation is also presented.

An evaluation of dynamic pituitary function tests in patients with pituitary tumours

In a prospective study of 26 patients with macroadenoma of the pituitary (14 secretory and 12 non-secretory), basal and stimulated pituitary hormone levels were used to detect hypothalamic dysfunction and to examine pituitary hormone secretion before and after hypophysectomy. Suprasellar tumour extention with hypothalamic compression occurred in 18 patients but was not consistently associated with hormonal tests indicative of hypothalamic dysfunction. In patients with secretory tumours, secretory activity was adequately assessed by basal hormone levels alone, which showed that surgery reduced hormone levels by a mean 85% in acromegaly and by a mean 55% in prolactinomas. Preoperatively, pituitary reserve of hormones not being hypersecreted was often normal, despite large tumour size and hypothalamic compression. Even after apparently complete pituitary removal at surgery, normal responses to stimulatory tests could sometimes be detected. Conventional dynamic tests are only of limited value in the assessment of hypothalamo-pituitary dysfunction in patients with large pituitary tumours and should not be used indiscriminately in such individuals requiring surgery.

Recent advances in the control and function of the anterior pituitary

Major advances in our understanding of the synthesis and release of anterior pituitary hormones have been made over the past several years. Neurons of the hypothalamus have been found to serve as "neuroendocrine transducers" in that they have both electrical and secretory functions. Peptidergic neurons respond to appropriate stimuli with a release of hypothalamic factors into the hypophyseal-portal system. These factors or hormones ultimately control the endocrine function of anterior pituitary cells. Three hormones, Thyrotropin Releasing Hormone (TRH), Gonadotropin Releasing Hormone (GnRH or LHRH) and somatostatin have been identified, synthesized and tested for clinical applications. The clinical assessment of pituitary function has been greatly improved by new and improved radioimmunoassays. One of the recent clinical advances in the area of pituitary disease has been the determination of the relatively high frequency of prolactinomas. Prolactin secreting microadenomas are an important and treatable cause of amenorrhea and infertility in young women. In addition, many pituitary tumors previously believed to be non-functional or "chromophobe adenomas" appear to be prolactinomas. Many new diagnostic and therapeutic techniques are continuing to be developed to improve our management of patients with hypothalamic-pituitary disease.

Cushing's disease presenting as amenorrhoea with hyperprolactinaemia: report of two cases

Two patients with Cushing's disease first presented with amenorrhoea, hyperprolactinaemia, and normal tomograms of the sella turcica. Both women underwent trans-sphenoidal removal of a pituitary microadenoma resulting in a decreased serum prolactin concentration in both, and cessation of galactorrhoea and return of menses in one of them. One woman became ACTH deficient while the other has persistent Cushing's disease. A survey of the literature on Cushing's disease and prolactinomas shows the association to be uncommon. A likely mechanism is secretion of both hormones by the microadenomas. These two patients illustrate the need for screening other pituitary hormone function in patients with hyperprolactinaemia.