Impact of macroprolactin on galactorrhea and the rate of patients possibly affected by macroprolactin

The clinical influence of macroprolactin (MPRL) is not clearly understood and the rate of patients potentially affected by MPRL is unknown. We investigated the influence of MPRL on the onset of galactorrhea and estimated the rate of patients with a proportion of MPRL fraction that may possibly affect galactorrhea. Data of patients with obstetric or gynecological symptoms who had undergone PRL fractionation testing were retrospectively analyzed. To evaluate factors influencing galactorrhea, a multivariate logistic regression analysis was performed and the adjusted odds ratios of MPRL for galactorrhea were calculated. Cutoff values for the total PRL level and the proportion of MPRL fractions for galactorrhea were determined by ROC analysis using a multivariate logistic model. The prevalence of patients with a proportion of MPRL fraction greater than or equal to the cutoff value for galactorrhea was estimated. The median proportion of MPRL fraction was 30.1% and increased as PRL level increased. Total PRL and MPRL had a significant influence on the onset of galactorrhea and the adjusted odds ratio was 1.09 in total PRL and 0.94 in MPRL. The rate of patients with a proportion of MPRL fraction that may possibly affect galactorrhea was estimated to be 33.5% of the study population, and thus found to be twelve times or more the number of macroprolactinemia patients. Future prospects for hyperprolactinemia may require diagnostic criteria using free prolactin levels and so MPRL fraction measurement is important for the diagnosis and treatment of patients with obstetric and gynecological symptoms.

Clinical and radiological findings in macroprolactinemia

Hyperprolactinemia is the most common abnormality of the hypothalamic-pituitary axis. The aim of this study was to investigate the clinical and radiological features of patients with macroprolactinemia. The study population consisted of patients with elevated serum prolactin (PRL) concentrations who presented to our Endocrinology outpatient clinic. Detection of macroprolactin (macroPRL) was performed using the polyethylene glycol precipitation method. Patients in which macroPRL made up more than 60% of total PRL levels were stratified into the macroPRL group, while the remaining patients were placed in the monomeric prolactin (monoPRL) group. A total of 337 patients were enrolled with a mean age of 33.8 ± 10.8 (16-66) years and a male/female ratio of 29/308. Eighty-eight of the patients (26.1%) had an elevated macroPRL level. The mean age in the monoPRL group was higher than in the macroPRL group (35.0 ± 10.1 vs. 30.7 ± 9.8, P = 0.016). The mean PRL levels (ng/ml) in the macroPRL and monoPRL groups were similar (168.0 ± 347.0 vs. 238.8 ± 584.9, P = 0.239). Frequency of amenorrhea, infertility, irregular menses, gynecomastia, and erectile dysfunction were also similar in both groups. More patients in the macroPRL group were asymptomatic compared to the monoPRL group (30.2 vs. 12.0%, P = 0.006). Compared to the macroPRL group, the monoPRL group had a higher frequency of galactorrhea (39.2 vs. 57.1%, P = 0.04) and abnormal magnetic resonance imaging findings (65.3 vs. 81.1%, P = 0.02). Elevated macroPRL levels should be considered a pathological biochemical variant of hyperprolactinemia that may present with any of the conventional symptoms and radiological findings generally associated with elevated PRL levels.

The prevalence of hyperprolactinemia and galactorrhea in patients with abnormal uterine bleeding

BACKGROUND

Abnormal uterine bleeding is one of the most common gynecological problems in women aged 15-45 years. The relationship of hyperprolactinemia with reproductive disorders, amenorrhea and irregular menstrual cycles has been known. The aim of the present study was to determine the frequency of hyperprolactinemia and galactorrhea in 15-45-year-old females with abnormal uterine bleeding.

METHODS

This analytic descriptive study was carried out on 100 women referred to a gynecology clinic for vaginal bleeding without any organic disorder. Consecutive sampling was performed.

RESULTS

Among the cases 61% had hyperprolactinemia and galactorrhea was reported in 48% of these patients. There was a significant association between hyperprolactinemia and galactorrhea (p = 0.003); 46% of patients with galactorrhea and 75% of patients without galactorrhea had a high level of prolactin. Galactorrhea and hyperprolactinemia had no significant association with the type of abnormal uterine bleeding. Among patients with undiagnosed vaginal bleeding, hyperprolactinemia was present in more than 50% of them and in 46% it was associated with galactorrhea.

CONCLUSION

Hyperprolactinemia that presents a gynecological problem may or may not be accompanied by galactorrhea, and galactorrhea cannot be a certain index for hyperprolactinemia.

[Irregular secretion of prolactin in infertile women with normoprolactinemic galactorrhea]

BACKGROUND

Abnormal frequency and pulse amplitud of prolactin secretion in micro and macroprolactinomas has been atributed to a dysfunctional tumoral lactotrope. Previous evidence suggests that non tumoral hyperprolactinemia is caused by a hypothalamic dysfunction. The regularity of prolactin secretion has not been studied with cuantitative methods in patients with normoprolactinemic galactorrhea (NPG) which could be considered an entity that precedes non tumoral and tumoral hyperprolactinemia.

OBJECTIVE

To analyze the 24-hour prolactin secretion pattern and its secretion regularity in a group of infertile women with normoprolactinemic galatorea.

PATIENTS AND METHODS

A transversal-comparative study was carried out in 6 infertile women with normoprolactinemic galactorrhea and 4 healthy women as controls. The 24 hour prolactin profile, the ratio night time mean concentration/daytime mean concentrattion (NM/DM ratio) and apparent entropy (Ap En, Ap En ratio) were compared in the two groups.

RESULTS

Blunting of the nyctohemeral rythm and nocturn hyperprolactinaemia occurred in patients with normoprolactinemic galactorrhea (NPG). NM/DM ratio was lower in patients with NPG than in controls (1.28 +/- 0.25 vs. 1.75 +/- 0.05; p= 0.01). Higher irregularity of prolactin secretion was found in patients with NPG (ApEn: 0.853 +/- 0.158 vs 0.608 +/- 0.171, p=0.04; Ap En ratio: 0.839 +/- 0.11 vs 0.661 +/- 0.14; p=0.04).

CONCLUSIONS

The irregularity of prolactin secretion in patients with NPG is not dependant on the presence of a pituitary tumour which suggests that a hypothalamic dysfunction underlies this condition. An irregular secretion and a higher daily mass production of prolactin in patients with NPG could explain both galactorrhea and infertility.

Incidence of Galactorrhea in Young Women Using Depot-Medroxyprogesterone Acetate

Galactorrhea is rarely mentioned as a possible side effect of the use of Depot-Medroxyprogesterone Acetate (DMPA). Over the last few years, we have noticed an increased number of patients complaining of galactorrhea. A review of clinical data showed that between 1999 and 2005, 360 adolescents in our clinic used DMPA for at least 6 months. After medical follow-up, 13 (3.6%) of these patients were found to have developed galactorrhea. The mean age of the patients was 19.4 years with a range from 13—24. Prolactin levels in these patients were normal, and in all subjects, the galactorrhea resolved spontaneously within the next year in both patients who continued use and those who discontinued use of DMPA. It appears that galactorrhea is a benign side effect and as previous reports have suggested, it did not seem to be related to changes in Prolactin levels in our patients. It is thought that this is a progesterone-mediated effect. We believe that reassurance and education of patients is sufficient and there is no evidence of need for further intervention. Since the sample size is small in this study, additional research is recommended as to validate the presence of progesterone-mediated effects secondary to the use of DMPA.

Olanzapine vs. other antipsychotics in actual out-patient settings: six months tolerability results from the European Schizophrenia Out-patient Health Outcomes study

OBJECTIVE

The European Schizophrenia Out-patient Health Outcomes study is an observational study investigating treatment in schizophrenia. We report treatment-emergent adverse events during the first 6 months of treatment.

METHOD

The rate of extrapyramidal symptoms (EPS), anticholinergic use, weight gain and sexual related dysfunctions were assessed in 8,400 out-patients.

RESULTS

Patients typical antipsychotics and risperidone experienced significantly more EPS and anticholinergic use than patients in the clozapine, olanzapine, and quetiapine cohorts. Patients treated with amisulpride, typical antipsychotics and risperidone were significantly more likely to have sexual related dysfunctions and/or amenorrhea. Increases in weight and body mass index occurred in all cohorts, but were significantly greater in the olanzapine and clozapine cohorts.

CONCLUSION

Patients treated with olanzapine, quetiapine and clozapine had better tolerability outcomes regarding EPS and sexual related dysfunctions compared with patients receiving risperidone, amisulpride and typicals. Patients treated with olanzapine and clozapine had higher weight increases than patients treated with risperidone, quetiapine and typicals.

Galactorrhea due to psychotropic drugs

Within the drug safety program in psychiatry AMSP ( Arzneimittelsicherheit in der Psychiatrie), severe adverse drug reactions (ADRs) are assessed. Currently 35 psychiatric hospitals and departments are participating in detecting severe ADRs. This paper focuses on prolactin-dependent ADRs such as gynecomastia and galactorrhea due to psychotropic medications. Related to the number of patients surveyed (122,562 from 1993 to 2000), these are rare events (0.03 % or 35 cases). Imputed drugs were mostly antipsychotics, but antidepressants were also imputed in single cases. In the group of antipsychotics, relative frequencies of galactorrhea were highest for amisulpride and risperidone and corresponded to the degree of D2 binding. Galactorrhea assessed as "severe" was accompanied by distressing symptoms such as pain, tension, enlargement of breasts, or soaked clothing. The AMSP data contribute to the knowledge on endocrine ADRs by the large number of patients examined and help clinicians select the appropriate drug if their patients have been prone to for these ADRs in the past.

Frequency of sexual dysfunction and other reproductive side-effects in patients with schizophrenia treated with risperidone, olanzapine, quetiapine, or haloperidol: the results of the EIRE study

Atypical antipsychotics seem to differ mainly in their tolerability profile. The aim of this cross-sectional study, the Estudio de Investigaci n de Resultados en Esquizofrenia (Outcomes Research Study in Schizophrenia; EIRE study), was to assess in a clinical setting the frequency of several side-effects related to haloperidol, risperidone, olanzapine, and quetiapine. This article addresses sexual dysfunction and other reproductive side-effects (gynecomastia, menorrhage, amenorrhea, and galactorrhea). We recruited outpatients diagnosed with schizophrenia according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria and who had received a single antipsychotic (risperidone, olanzapine, quetiapine, or haloperidol) for at least 4 weeks. During a single visit, we collected data, including demographic and clinical characteristics, current antipsychotic and concomitant treatment, and adverse effects listed in a modified version of the UKU Scale. We used a Chi-squared test to determine pairs comparisons of the frequency of adverse reactions between treatments. To estimate risk of a given adverse reaction with a given treatment, we used a logistic regression method. We assessed 636 evaluable patients out of 669 recruited. Frequency of sexual dysfunction was high with haloperidol (38.1%) and also with olanzapine (35.3%), quetiapine (18.2%), and risperidone (43.2%). We found the frequency of other reproductive side-effects to be relatively low with all four drugs: haloperidol (6.9%), olanzapine (6.4%), quetiapine (2.7%), and risperidone (11.7%). Sexual dysfunction appeared to be dose-related with haloperidol, risperidone, and olanzapine. Risperidone and olanzapine showed a higher risk of sexual dysfunction and other reproductive sideeffects than haloperidol. Quetiapine showed a lower risk of sexual dysfunction during short-term treatment (< 12 weeks). However, data on longer-term treatment (> 12 weeks) are lacking. Our results suggest that none of the atypical antipsychotics that we studied significantly improved sexual dysfunction and other reproductive side-effects of the conventional antipsychotic, haloperidol, in stabilized patients during long-term treatment. Quetiapine appears to improve this profile during short-term treatment; however, longterm data, with larger samples, are required with this latter drug.

Nipple discharge

The evaluation and management of nipple discharge can be undertaken with minimal difficulty by performing a careful history and examination and following a logical thought process in linking the type of discharge with the suitable mode of treatment. In this manner, the patient's discharge can be efficiently and thoroughly evaluated.

Risk factors for secondary amenorrhea and galactorrhea

OBJECTIVE

Analyses were undertaken to identify factors that may predispose women to secondary amenorrhea or galactorrhea, frequent sources of abnormal reproductive function.

METHODS

Data were gathered from interviews with 252 women with secondary amenorrhea or galactorrhea from four clinical centers, along with neighborhood controls matched to each case. Univariate comparisons were made for clinical and demographic factors of the study subjects.

RESULTS

Patients with amenorrhea and normal prolactin (PRL) levels and their matched controls tended to be younger than those with amenorrhea and elevated PRL or than menstruating patients with galactorrhea alone and their matched controls. Patients with amenorrhea and normal PRL also were significantly more educated and were older at menarche than their controls, while amenorrhea patients with elevated PRL or patients with galactorrhea alone did not differ significantly from their controls in age at menarche or educational level. More patients with galactorrhea alone had reported menstrual pain to their physicians and had significantly longer menstrual periods than their matched controls. Patients with galactorrhea alone also weighed more than their controls 2 years prior to diagnosis, a difference that remained after stratification by parity, although only statistically significant among women who had had one or two pregnancies. Finally, significantly fewer patients with amenorrhea than controls were smokers. Thus, these disorders may not be due to anti-estrogenic effect or to low estrogen levels which have been associated with smoking.

Copious lactation following augmentation mammaplasty: an uncommon but not rare condition

The senior author encountered many patients who experienced copious galactorrhea following augmentation mammaplasty and yet there are only four cases reported in the medical literature. A retrospective chart review of 1,000 breast augmentation patients operated on by the same surgeon under general anesthesia revealed eight documented cases of copious postaugmentation lactation. The lactation started an average of 6.6 days following surgery and was self-limited with an average duration of 5.2 days. The charts of the patients who lactated were studied in detail for possible contributing factors. Eight controls, matched for age, race, parity, implant type, implant size, hormonal therapy (birth control pill), surgical incision, and prosthesis placement site, were similarly studied and statistical analysis performed on the differences between these two groups of patients. The only statistically significant factor found between the groups was gravidity (P value < 0.03). One patient who lactated postoperatively was nulliparous. The postoperative occurrence of lactation does not increase postoperative morbidity. Presenting characteristics, possible contributing factors, and other multifactorial causes of this uncommon postoperative occurrence are discussed.

Low serum prolactin levels in native women at high altitude

OBJECTIVES

To determine the serum prolactin levels in women at sea level and at high altitude, and the prevalence of hyperprolactinemia in both places.

METHODS

The study included 303 normal women and 112 women with any reproductive dysfunction (menstrual abnormalities, galactorrhea or dysmenorrhea). From these, 228 were living in Lima at 150 m above sea level and 187 were living in Cerro de Pasco at 4340 m. Normal women included nonpregnant and pregnant women. Menstrual abnormalities included amenorrhea, oligomenorrhea and polymenorrhea.

RESULTS

Serum prolactin levels were significantly lower in nonpregnant and pregnant women living at high altitude than at sea level. Prevalence of hyperprolactinemia, galactorrhea and menstrual abnormalities were significantly lower at high altitude than at sea level.

CONCLUSIONS

It is concluded that menstrual abnormalities associated with hyperprolactinemia is a rare condition at high altitude. The low serum prolactin level observed at high altitude could be due to a high dopaminergic activity.

Case-control study of galactorrhea and its relationship to the use of oral contraceptives

A case-control study was performed to determine the relationship between galactorrhea and the use of oral contraceptives as well as other risk factors. The cases included all 109 Olmsted County residents who satisfied the diagnostic criteria for galactorrhea between 1970 and 1980. Control subjects were selected from a sampling frame of all medical registrations and matched to the cases by age, year, and residency. Pituitary adenomas were strongly associated with galactorrhea, as the relative risk was 23.2 (95% confidence interval 2.0 to 90.0). In galactorrhea cases without pituitary adenomas there was an association with oral contraceptives (ever use versus never use), as the relative risk was 2.3 (95% confidence interval 1.3 to 4.4). Among current users of oral contraceptives, the risk of galactorrhea was not increased, but there was a trend of diminishing risk with duration of use. The estimate of relative risk was 3.1 after discontinuation of oral contraceptive use and was highest for the first year after discontinuation (5.5), compared with a year or more after discontinuation (2.1). Thus, galactorrhea was associated with the cessation of oral contraceptives.

Hyperprolactinemia in women with paternal deprivation during childhood

It was reported that most females with prolactinoma, idiopathic hyperprolactinemia, or euprolactinemic galactorrhea were reared either without their father or with an alcoholic, violent father. To gain further insight into this association, a group of sisters of patients with prolactinoma (generally exposed to the same environment as the patients') and a control group were studied. Women with paternal deprivation during childhood differed from the women who had normal childhoods in that they had: 1) higher mean serum prolactin concentration (14.7 versus 9.4 ng/mL; P less than .001); 2) higher incidence of hyperprolactinemia (12 of 50 versus three of 59; P less than .005); and 3) higher incidence of galactorrhea (14 of 50 versus seven of 59: P less than .03). These observations support the contention that paternal deprivation during childhood is associated, in a minority of women, with a predisposition to develop hyperprolactinemia and presumably, prolactinoma later in life. A hypothesis on the possible mechanisms of a casual relationship is presented.

Nonpuerperal breast secretion. Its relation to the use of oral contracetpives

The occurrence of breast secretion more than 1 year postpartum was studied in 800 healthy, parous women of childbearing age. Among of 418 women who were using a combination-type oral steroid contraceptive, the incidence of breast secretion was lower than among the nonusers. The incidence of bilateral secretion decreased with increasing duration of use of the oral contraceptives. Statistical material is presented for the incidence of breast secretion as related to age. time elapsed since last delivery, and duration of nursing the last child. Brownish secretion rather than white or yellowish is seen more often in women over 30 years of age. Various menstrual irregularities (excluding amenorrhea) do not appear to be associated with an increased incidence of breast secretion.

Incidence of galactorrhea in ovulatory and anovulatory females

The incidence of galactorrhea in 480 ovulatory females was compared to that in 383 anovulatory females. One percent of the ovulatory and 3.2% of the anovulatory patients had bilateral galactorrhea. The probability (P) of these two groups being from the same population was less than 0.02.