3. Introductions
• Prolactin (PRL) is a polypeptide protein hormone
secreted by the lactotroph cells in the anterior pituitary
gland .
• Suppressed by hypothalamic dopamine to act on
Lactotroph D2 receptors .
• Prolactin (PRL) is the hormone act as stimulation &
maintenance of milk production in the breast .
5. Epidemiology
• Most common functional pituitary adenomas .
• Prolactinoma account for 40 % of pituitary tumor .
• Microprolactinomas are more frequent in women .
• Macroprolactinomas are more frequent in men .
• Gender : femal more than male 10 :1
• Age : 20-50 years .
• Some growth hormone producing tumors also
cosecrete PRL
6. Clinical Manifestations
• Hormonal Effect :
• Women : infertility, oligomenorrhea, amenorrhea or
rarely galactorrhea .
• Men : decreased libido, impotence, infertility,
gynecomastia, or rarely galactorrhea .
10. • Biochemical : by serum PRL
concentration
* Normal range for serum prolactin is 5 - 20 ng/mL .
* Serum prolactin values above 200 ng/mL usually
indicate the presence of a lactotroph adenoma
• Hook effect : can be observed in macroprolactinomas.
the extremely high PRL levels cause antibody saturation , the
resulting in an artifactually low reported value .
This can be eliminated by dilution of serum samples.
* Other s: FSH ,LH ,GH ,TSH, FT4 , RFT, LFT .
11. Ranges of serum prolactin concentrations in
several causes of hyperprolactinemia
12. • Imaging : MRI Of Head
* Should be performed in a patient with any degree of
hyperprolactinemia to look for a mass lesion in the
hypothalamic-pituitary region .
13. Treatment
* The indications for treatment :
1) Neurologic symptoms .
2) Hypogonadism or other symptoms .
* The corner stone treatment of prolactinomas are
medical treatment .
14. 1) DOPAMINE AGONISTS
Dopamine agonists decrease prolactin secretion and
reduce the size of the lactotroph adenoma in more than
90 % of patients.
Decrease symptoms within days .
Decrease in serum prolactin within 2-3 weeks .
Decrease in size within 6 weeks ... ( 6 month ) .
15. 1) DOPAMINE AGONISTS
Bromocriptine : It was given at least twice a day .
1.25 -2.5 mg PO at bedtime or with dinner.
( max. 15 mg / d )
Cabergoline : administered once or twice a week .
0.25 mg twice /wk or 0.5 mg once/wk .
Adverse effects : Common Less common
Nausea Nasal stuffiness,
Postural Depression, Raynaud
hypotension phenomenon, Constipation
Mental fogginess
valvular heart disease
16. 1) DOPAMINE AGONISTS
In a multicenter, randomized, 24-week trial conducted in
459 hyperprolactinemic women *
Cabergoline Bromocriptin
Normal PRL 83% 59%
Pregnancies 72% 52%
(Ovulation)
Stopped S/E 3% 12%
* Webster J, Piscitelli G, Polli A, et al.A comparison of cabergoline and bromocriptine in the treatment of
hyperprolactinemic amenorrhea. Cabergoline comparative Study Group.N Engl J Med 1994;331(14):904–9 .
18. 2)TRANSSPHENOIDAL SURGERY
* The indications for surgery :
1) Patients who do not respond to medical treatment or
those who show progression after an initial response to
medical treatment .
2) Women who have a microadenoma, desire pregnancy,
and cannot tolerate medical treatment.
19. 3) RADIATION THERAPY
* The indications for radiation :
radiation is primarily used to prevent regrowth of
residual tumor in a patient with a very large
macroadenoma after transsphenoidal debulking .
20. 4) ORAL CONTRACEPTIVE
* The indications for Estrogen- progestin :
can be considered as therapy in women with
symptomatic microprolactinomas IF :
women cannot tolerate or
do not respond to dopamine agonists or
do not want to become pregnant.
21. Follow Up
* After one month of therapy, the patient should be
evaluated for side effects and serum prolactin should be
measured , So :
If the serum PRL is normal and no S/E So,
(continued).
If the serum PRL not decreased to normal but no S/E ,
the dose should be increased gradually to as much as
1.5 mg of Cabergoline 2 or 3 times / week or 5 mg of
Bromocriptine 2 times / day. Whatever dose results in a
normal serum prolactin value should be continued
If the prolactin has been normal for two or more years and no
adenoma is seen on MRI So, discontinuation of the drug .
22. SUMMRAY
• Most common functional pituitary adenomas
• Most frequently in women with gender ratio of 10:1.
• Diagnosis clinically, biochemically & imaging .
• Macroadenoma with low PRL levels ( hook effect) .
• MRI should be performed to confirm the diagnosis .
• Medical therapy with DA is the treatment of choice .
• Cabergoline is the first-line treatment
• Transsphenoidal surgery remains an option when
medical therapy is ineffective .
• Radiotherapy represents the last option .
