The most common functional pituitary adenoma is hyperprolactinemia.
It is the most common functional pituitary adenoma, with hyperprolactinemia, amenorrhea and breast milk overflow in women, and erectile dysfunction in men. The cause of the disease is still unclear, and may be related to the activation of tumor genes and the inactivation of oncogenes, with pharmacological treatment as the mainstay, and surgical treatment and radiation therapy if necessary.
Definition
Prolactinoma is a type of pituitary adenoma, which is the most common functional pituitary adenoma and is mostly benign.
Classification
Prolactinomas are classified according to the size of the tumor and can be divided into the following two categories.
Microadenoma: tumor diameter ≤10mm.
Macroadenoma: tumor diameter >10mm.
Incidence
Prolactinomas account for about 40% to 45% of all functional pituitary adenomas. They are more common in female patients between 20 and 50 years of age, and the male to female ratio in adult patients is about 1:10.
Causes
Causes
The cause of prolactinoma is still unclear.
Currently, it is believed that activation of oncogenes and inactivation of oncogenes may promote the formation of prolactinoma.
Some scholars also believe that the pathogenesis may be related to the disorder in the regulation of prolactin-releasing factor (PRF) and prolactin-releasing inhibitory factor (PIP).
Symptoms
Main Symptoms
Clinical manifestations of hyperprolactinemia
Females
Menstrual changes and infertility: Hyperprolactinemia can cause menstrual disorders and reproductive dysfunction in women. It manifests as repeated spontaneous abortions, ovulation disorders, dysfunctional uterine bleeding (manifested as irregular uterine bleeding with sporadic or sudden increase in blood volume), scanty menstruation, amenorrhea and infertility.
Breastfeeding: in about 30% to 80% of female patients, symptoms of breastfeeding may occur during non-pregnancy and non-lactation periods [1].
Other symptoms: such as weight gain, progressive bone pain, decreased bone density, and osteoporosis. A few may present with hirsutism and acne.
Male
Erectile dysfunction: erectile dysfunction is one of the earliest clinical manifestations of hyperprolactinemia. It can also manifest as inability to ejaculate and orgasmic disorder.
Decreased libido: manifested as decreased or even disappeared interest in sexual behavior.
Hypospadias and male infertility: Hyperprolactinemia can lead to a significant decrease in the function of sperm production in men to the point of infertility.
Hypoplasia of secondary sexual characteristics: manifested as slower growth of beard, forward shift of hairline, thinning of pubic hair, softening of testicles, muscle flaccidity, and development of male mammary glands.
Prolactinoma compression symptoms
It may manifest as headache, vision loss, visual field defects and other symptoms of cerebral nerve compression, seizures, and cerebrospinal fluid nasal leakage.
Acute pituitary stroke occurs in a small number of patients, which manifests as sudden severe headache, vomiting, vision loss, and motor nerve palsy (manifested as ptosis and inability to retract the eyeballs internally).
Complications
Osteoporosis
Reduced estrogen levels can lead to accelerated bone loss, causing osteoporosis.
The main manifestations are peripheral bone and joint pain, shorter stature, hunchback, and susceptibility to fracture.
Acute pituitary stroke
If spontaneous bleeding occurs in pituitary adenoma, acute pituitary stroke may occur in a few patients.
The main manifestations are sudden severe headache, vomiting, and vision loss.
Consultation
Department of Medicine
Endocrinology
Women with menstrual disorders, abnormal lactation, loss of libido; men with erectile dysfunction, breast development, etc. are advised to consult the doctor promptly.
Neurosurgery
For headache, vision loss, visual field defect, seizure, cerebrospinal fluid leakage, etc., timely consultation is recommended.
Emergency Department
In case of sudden severe headache, vomiting, loss of vision, coma, etc., it is recommended to consult a doctor immediately.
Preparation for medical treatment
Information on how to get to the doctor: registration, preparation of documents, and frequently asked questions.
Tips for seeking medical treatment
Relax and get a good night’s rest before visiting the doctor.
Wear loose clothing and no metal jewelry.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Do women have prolonged menstrual cycles, low menstrual flow, infertility, breast overflow, etc.?
Do men have erectile dysfunction, loss of libido, infertility, etc.?
Are there headaches and for how long?
Are there any vision abnormalities, such as difficulty seeing or seeing at all?
Medical History Checklist
Is there a family history of tumors such as pituitary adenomas?
Are there any drug or food allergies?
Any recurrent spontaneous abortions, infertility, osteoporosis, etc.?
Checklist
Test results in the last six months, which can be brought to the doctor’s office
Laboratory tests: prolactin measurement, etc.
Imaging tests: cranial CT, cranial magnetic resonance imaging, etc.
Medication list
Medication used in the last 3 months, if available in boxes or packages, you may bring them to the doctor
Dopamine agonists: bromocriptine, cabergoline, etc.
Diagnosis
Diagnosis based on
medical history
There may be a family history of pituitary adenoma.
There may be a history of recurrent spontaneous abortions, infertility, and osteoporosis.
Clinical manifestations
Women may have prolonged menstrual cycle, scanty menstrual flow, infertility, breast milk overflow and bone pain.
Men may have erectile dysfunction, decreased libido, infertility, anterior hairline, thinning pubic hair, softening of testicles, muscle laxity, and gynecomastia.
There may be headache, difficulty in seeing or seeing at all.
Laboratory Tests
Prolactin Measurement
Blood prolactin test can determine whether the blood prolactin level is increased or not, and can clearly diagnose the presence of hyperprolactinemia. If the serum prolactin is >100~200ug/L and other special causes of hyperprolactinemia are excluded, the diagnosis of prolactinoma is supported.
Before checking blood prolactin normal breakfast (type of carbohydrate, avoid protein and fatty foods), at 10:30 to 11:00 a.m. after resting for half an hour vein puncture blood [1].
Imaging.
Pterygoid radiographs or tomograms can be taken to observe whether there is any enlargement of the pterygoid.
CT and magnetic resonance (MRI) examination of the saddle region can directly observe the presence or absence of pituitary tumor.
MRI enhanced images of the saddle region are more helpful in the detection of pituitary adenomas, and dynamic enhancement imaging helps in the detection of pituitary microadenomas.
Differential diagnosis
Physiologic hyperprolactinemia
Similarities: Both can have the manifestations of hyperprolactinemia, such as menstrual disorders, abnormal lactation, infertility, decreased libido in women; erectile dysfunction, breast development in men.
Differences: Physiological hyperprolactinemia mainly occurs during pregnancy, breastfeeding or stress, with elevated prolactin levels, but without the presence of pituitary tumors.
Pharmacologic hyperprolactinemia
Similarities: Both can be characterized by hyperprolactinemia, such as menstrual disorders, abnormal lactation, infertility, and loss of libido in women; erectile dysfunction and breast development in men.
Differences: Many commonly used medications can cause elevated prolactin levels, such as oral contraceptives, metoclopramide, domperidone, reserpine, cimetidine, as well as antipsychotics (e.g. haloperidol) and antidepressants (e.g. phenelzine).
Treatment
The aim of treatment is different for prolactinomas of different sizes.
The aim of prolactin microadenoma treatment is to control prolactin levels and preserve gonadal and sexual function.
In addition to controlling prolactin levels and preserving pituitary function, the treatment of prolactin macroadenomas also aims to reduce the size of the tumor in order to improve clinical symptoms and prevent recurrence.
Drug therapy
Dopamine agonists
The treatment of choice for patients with prolactinomas, currently the main ones are bromocriptine and cabergoline, others are quinagolide.
Bromocriptine
Bromocriptine is our recommended treatment of choice for prolactinoma.
Bromocriptine treatment should start with a small dose and gradually increase the dose according to the blood prolactin level, and if the response is not significant, it can be increased to a therapeutic amount within a few days.
Bromocriptine only causes reversible shrinkage of prolactinomas and inhibits tumor cell growth, but prolactinomas will resume growth and cause reproduction of hyperprolactinemia when treatment is stopped, so long-term treatment is mostly required.
Common adverse reactions to bromocriptine are nausea, vomiting, headache, dizziness, and postural hypotension.
Bromocriptine is contraindicated in persons who are hypersensitive to its components, in patients with poorly controlled hypertension, in patients with coronary artery disease or other severe cardiovascular disease, in patients with a history of severe psychiatric disorders, and in patients with pre-existing valvular disease.
Carmegoline, Quinagolide
Actinomycin and quinagolide are highly selective dopamine D2 receptor agonists, which are substitutes for bromocriptine, with stronger prolactin inhibition and relatively fewer adverse effects, and longer duration of action.
It is indicated for patients with prolactinoma who are bromocriptine resistant or intolerant to bromocriptine therapy.
Surgery
Pituitary tumor resection
Surgical approach
Mostly use transsphenoidal approach surgery.
Short-term administration of bromocriptine under doctor’s supervision before surgery can shrink the pituitary tumor and reduce intraoperative bleeding, which helps to improve the efficacy.
There is a possibility of complications after surgery, such as damage to the pituitary gland, pituitary stalk or optic cross, resulting in urolithiasis, cerebrospinal fluid leakage, intracranial infection and so on.
Indications for surgery
Ineffective drug treatment or poor results after taking drugs.
Those who are unable to tolerate the large response to medication.
Huge pituitary adenoma with obvious visual field disorder, which has not been significantly improved after drug treatment for a period of time.
Aggressive pituitary adenomas with cerebrospinal fluid leakage.
Those who refuse to take long-term medication.
Recurrent pituitary adenoma.
Radiation therapy
Radiation therapy is mainly used for patients with aggressive adenomas, residual or recurrent tumors after surgery, ineffective or intolerant drug therapy, contraindications to or refusal of surgery, and patients who do not want to take long-term medication.
Radiation therapy may cause complications such as hypopituitarism, optic nerve damage, tumor induction, etc., and the therapeutic efficacy is slow, so simple radiation therapy is generally not advocated.
Prognosis
Cure
Most patients have a favorable prognosis after prompt and aggressive treatment.
Bromocriptine drug therapy can only inhibit the proliferation of pituitary tumor cells, and the adenoma may grow again after short-term use and discontinuation of the drug, leading to recurrence.
Among patients with normal prolactin levels after surgical treatment, 0% to 40% of patients will experience recurrence in long-term observation, and the recurrence rate is about 20% at 5 years after surgery [1].
Hazards.
Symptoms such as menstrual disorders, abnormal lactation, and gynecomastia can occur, affecting normal life and work.
It may cause infertility, decreased libido, erectile dysfunction, and difficulty in sexual intercourse, which may cause psychological burden of patients.
If not treated in time, it may cause complications such as osteoporosis and acute pituitary stroke, which may be life-threatening.
Daily
Daily management
Dietary management
Eat a balanced diet with plenty of fresh vegetables and fruits.
Avoid spicy and irritating food, and use less seasoning when cooking.
Lifestyle Management
Work and rest regularly and avoid staying up late.
Take appropriate physical exercise, such as brisk walking, yoga and Tai Chi.
Quit smoking and try to avoid passive smoking.
Stay warm when going out in cold weather.
Choose cotton and comfortable underwear to avoid long-term stimulation of the breasts.
Psychological support
Maintain optimism in daily life, face the disease positively, build up confidence in overcoming the disease, and try to avoid repressed and anxious psychological state.
Disease monitoring
Observe menstruation, abnormal lactation, etc. and keep records.
If symptoms are not relieved after treatment, it is necessary to consult the doctor in time and adjust the treatment plan according to the doctor’s instruction.
Follow-up review
Long-term review and regular monitoring of blood prolactin level should be carried out according to doctor’s instructions.
After surgery, patients need to undergo imaging examination after 3 months, combined with prolactin and other endocrine changes, to understand the extent of tumor removal, and then review every six months or one year, the specific time of review needs to follow the doctor’s instructions.
Prevention
Prolactinoma has no effective preventive measures because the cause is not clear.
A good lifestyle may be helpful in the prevention of prolactinoma. Try to avoid exposure to harmful environments, such as chemical poisons and radiation.
Pay close attention to your own health and have regular medical checkups for early detection and treatment.