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Endocrinology - Chapters > Chapter 100- Galactorrhea > Flashcards

Chapter 100- Galactorrhea Flashcards

0
Q

polypeptide hormone that is secreted by the lactotroph cells of the anterior pituitary gland

A

prolactin

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1
Q

where is prolactin secreted from?

A

anterior pituitary

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2
Q

what inhibits prolactin?

A

tonic inhibitory control, predominately by dopamine

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3
Q

During pregnancy and lactation, the prolactin content of the pituitary increases _______.

A

10-20 fold

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4
Q

Discharge of milk or colostrum from the breast in the absence of nursing

A

Galactorrhea

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5
Q

When galactorrhea occurs with accompanied by distributed menses or infertility, it suggests the possibility of _______ and the associated risk for ________.

A

hyperprolactinemia; pituitary neoplasm

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6
Q

When a patient presents with glactorrhea, underlying _______ disease must be carefully considered.

A

pituitary disease

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7
Q

During pregnancy and lactation, the prolactin content of the pituitary increases a ________.

A

10 to 10 fold

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8
Q

When can galactorrhea occur?

A

In the setting of normal or elevated serum prolactin level

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9
Q

What is the upper normal value for serum prolactin in most laboratories _____.

A

20 ng/mL

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10
Q

is believed to be a consequence of local breast stimulation or irritation in women with hormonally primed breast tissue.

A

Normoprolactinemic Galactorrhea

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11
Q

It is hypothesized that stimulation of the breast tissue may cause a milk, transient elevation in prolactin secretion, although this is not sustained. Many cases of Normoprolactinemic Galactorrhea are associated with _______ or ______.

A

a distant pregnancy or the use of the oral contraceptives

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12
Q

In Normoprolactinemic Galactorrhea, gonadal function is preserved with ______ and _________.

A

menses, and fertility remaining normal

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13
Q

what develops as a consequence of excessive prolactin production

A

Hyperprolactinemic galactorrhea

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14
Q

What causes Hyperprolactinemic Galactorrhe

A

loss of hypothalamic inhibition of lactotrophs in the anterior pituitary or by the development of an autonomously functioning pituitary adenoma
*in a RARE case, hyperprolactinemia results from a decreased clearance of prolactin (RENAL FAILURE)

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15
Q

T/F Galactorrhea will always occur in the presence of high prolactin levels.

A

FALSE!

** the breast must be primed by estrogen which accounts for the rarity of the condition in men

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16
Q

What are the most common symptom of hyperprolactinemia?

A

amenorrhea and infertility

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17
Q

Galactorrhea occurs in ____ % of women.

A

80%

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18
Q

What are the most common physiologic causes of hyperprolactinemia?

A

pregnancy and lactation

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19
Q

How will dopamine cause hyperprolactinemia?

A

Because the secretion and release of prolactin are under tonic inhibition of dopamine, any process that interferes with dopamine secretion and release will cause hyperlactinemia.

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20
Q

What daily activities can cause prolactin to increase? Under these physiological circumstances, the levels are rarely higher than _______.

A

exercise, meals, chest wall stimulation, and physical and psychological stress
40ng/mL

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21
Q

What medications will cause hyperprolactinemia?

A

medications that effect dopaminergic activity

  1. Phenothiazines
  2. Thioxanthenes
  3. butyrophenones
  4. Tricyclic antidepressants
  5. monamine oxidase inhibitors
  6. Selective serotonin reuptake inhibitors
  7. Reserpine
  8. Methyldopa
  9. Verapamil
  10. Metoclopramide
  11. Cimetidine
  12. Estrogen
  13. Opiates
  14. Cocaine
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22
Q

compression of the pituitary stalk by non secreting pituitary tumors and craniopharyngiomas, acromegaly, and primary hypthyroidism (owing to thryoid-releasing hormone stimulation of lactotrophs).

A

Hyperprolactinemia/ Pituitary Diseases

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23
Q

What are very high serum concentrations of prolactin associated with?

A

autonomously functioning prolactinomas derived from lactotrophs in the anterior pituitary

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24
Q

The degree of hyperprolactemia tends to correlate with _____.

A

tumor size

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25
Q

Prolactinomas larger than 10mm in diameter (“macroadenomas”) are typically associated with prolactin levels greater than ______.

A

250 ng/mL and sometimes greater than 1000 ng/mL

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26
Q

Except in pregnancy, serum prolactin in excess of ________ is almost always the result of prolactinoma.

A

250-300 ng/mL

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27
Q

Microadenomas are less than ______ may produce less impressive elevations.

A

<10 mm in diameter

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28
Q

What are the associated symptoms of hyperprolactinemia?

A

they are at risk for hypogonadism, they may experience, in addition to galactorrhea, disturbed menses, amenorrhea, infertility, and osteoporosis.

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29
Q

Prolactin elevations greater than 100 ng/mL are typically associated with findings of hypogonadism with _______ due to _____.

A

estrogen deficiency, due to inhibition of the release of gonadotropin-releasing hormone and subsequent inhibition of luteinizing hormone and follicular stimulating hormone.

30
Q

Moderate elevations of 50-100 ng/mL may cause a ______ due to ______.

A

a short luteal phase of the menstrual cycle due to insufficient progesterone secretion, but even mild hyperprolactinemia can cause infertility

31
Q

Men with hyperprolactinemia commonly have ……

A

hypogonadism and report impotence, infertility, decreased libido, gynecomastia, and rarely galactorrhea.

32
Q

Men and women with a substantially enlarged sellar mass may complain of

A

headache or a visual field cut.

33
Q

The differential diagnosis of galactorrhea can be organized according to whether …..

A
  1. prolactin is elevated
  2. whether an elevation in prolactin is the result of a decrease in hypothalamic inhibition
  3. whether an elevation in prolactin is the result of overproduction by a functioning adenoma.
34
Q

Only ____ of patients with galactorrhea have hyperprolactinemia.

A

20%

35
Q

Prolactinoma is the leading cause of patients with ___,___, and ____.

A

glactorrhea, amenorrhea, and hyperprolactinemia.

36
Q

What should be ruled out in women with hyperprolactinemia.

A

if they are childbearning age, rule out pregnancy

37
Q

What should the history for workup of galactorrhea include?

A

questioning about

  1. menstrual pattern (oligomenorrhea, amenorrhea)
  2. recent pregnancy
  3. infertility
  4. medicine
  5. change in libido
  6. symptoms of hypothyroidism
  7. breast stimulation
  8. chest trauma
  9. presence of headache or visual complaints
38
Q

Should medications be asked about when a patient is recieving a history workup for galactorrhea?

A

yes, especially oral contraceptives and drugs that can block central dopaminergic transmission

39
Q

Has there been an increased risk in breast cancer for a patient who is diagnosed with galactorrhea?

A

no

40
Q

What physical exam should be done on a patient with galatorrhea?

A

a detailed examination of the breasts to be sure the discharge is indeed milky and not caused by local breast disease, although no increased risk for breast cancer has been found in patients with true galactorrhea.

41
Q

What two tests are important when examining a patient for galactorrhea but usually the findings are normal?

A

confrontation testing of the visual fields; fundoscopy examination

42
Q

Should hyperthyroidism or hypothyroidism be noted upon examination of a patient with galactorrhea?

A

hypothyroidism

**Any signs of hypothyroidism should be noted and then confirmed by measuring the thyroid stimulating hormone level

43
Q

In men, Hyperprolactinemia may cause __________ with findings of imptence, decreased libido, infertility, gynecomastia, and, rarely galactorrhea (due to less estrogen priming of breast tissue compared with women).

A

hypogonadotropic hypogonadism

44
Q

During an examination of a patient with galactorrhea, you find signs of hypothyroidism. How would u confirm hypothyroidism?

A

testing the thyroid stimulating hormone levels

45
Q

The development of accurate prolactin assays and the association of galactorrhea with high prolactin levels and pituitary tumors have made determination of the _________ an essential part of the diagnostic evaluation.

A

serum prolactin concentration

46
Q

What can cause prolactin levels to be transiently elevated, but NO higher than 40 ng/mL? What would u need to do in these conditions to confirm hyperprolactemia?

A

stress, time of day, sleep, meals, or breast stimulation
-when prolactin levels are transiently elevated, but no higher than 40 ng/mL you would need to measure multiple times to confirm the levels are elevated!

47
Q

Prolactin levels between ____ and ____ ng/mL can be found with any cause of hyperprolactinemia. However values greater than _____ usually indicate a PROLACTINOMA.

A

20-200 ng/mL

>200= PROLACTINOMA

48
Q

The patient with galactorrhea and amenorrhea is at increased risk for a ______ ________, and her prolactin concentration must be measured unless the explanation for both is apparent (e.g. recent pregnancy, medication).

A

pituitary neoplasm

49
Q

In up to 10% of patients with hyperprolactinemia, an elevation of ________ is seen.

A

Macroprolactin (results from the binding of monomeric prolactin to an endogenous antiprolactin autoantibody)

50
Q

Patients with galactorrhea, menstrual irregularities, and an otherwise unexplained elevation in serum prolactin should undergo _______. _________ is the procedure of choice.

A

neuroimaging of the sellar region.
Magnetic resonance imaging with gadolinium enhancement is the treatment of choice
**computed tomography is a reasonable alternative if MRI is unavailable

51
Q

T/F Microadenomas can be difficult to detect, although the absence of a visible lesion rules out an anatomically threatening neoplasm.

A

true

52
Q

T/F Patients with mild unexplained elevations of prolactin (<200 ng/mL) should not undergo neuroimaging of the pituitary region.

A

false.

  • **THEY SHOULD
  • *A sellar or parasellar mass can be responsible for a mild prolactin elevation due to compression of the pituitary stalk, and some pituitary tumors are poorly functioning.
53
Q

What kind of test should be performed in all patients with a sellar mass or visual symptoms?

A

formal visual field testing

54
Q

Patient is diagnosed with galactorrhea but presents with regular menses and a normal prolactin level, NO EVIDENCE OF A MASS LESION What is your treatment method?

A
  • the likelihood of a clinically important pituitary tumor is unlikely.
  • can be followed carefully with periodic determinations of prolactin, usually at 1-year intervals
  • if prolactin levels become elevated, neuroimaging of the sella can be pursued
55
Q

Patient with galactorrhea secondary to the use of dopaminergic blocking agents, and NO EVIDENCE OF A MASS LESION. How do you treat this patient?

A
  • a reduced dose of the drug, although full cessation may be necessary to terminate symptoms
  • prolactin levels begin to fall within days of stopping medications that cause hyperprolactinemia
  • *-if hypothyroidism is the contributing factor, it should be corrected
56
Q

_______ = less than 10mm

A

microadenomas

57
Q

T/F Long term studies of untreated patients demonstrate that in 80% - 90% of cases, the size of a micoadenoma remains the same or the tumor regresses with time; only 10-20% contine to grow.

A

true

58
Q

T/F In microadenomas that grow, the correlation between tumor size and prolactin level are the same.

A

FALSE!

*they do not correlate, therefore you should monitor BOTH ,prolactin levels and tumor size closely

59
Q

What are some associated risks of microadenomas?

A
  1. menstrual irregularities
  2. gonadal dysfunction
  3. severe galactorrhea
  4. infertility
  5. Osteoporosis
60
Q

What is the treatment of choice for prolactinomas?

A

dopaminergic agonists: Bromocriptine & cabergoline

**these drugs inhibit prolactin synthesis, secretion, and cellular proliferation

61
Q

What is the common approach to bromocriptine therapy for patients with a symptomatic microadenoma?

A

2 year course of treatment followed by a trial of cessation

62
Q

What is the common dose of Bromocriptine needed to control symptoms of a microadenoma?

A

2.5 - 10 mg/d

63
Q

What are the most common side effects of Bromocriptine?

A

nausea, orthostatic hypotension, and dizziness, which can be minimized by administering the drug at bedtime with a snack

64
Q

a nonergot agonist, is a long lasting dopamine agonist with a high affinity for lactotroph dopamine receptors. Has fewer side effects than bromocriptine, but is more expensive. What drug is this?

A

Cabergoline

65
Q

How is cabergoline administered?

A

twice a week in a dose of .25 mg

66
Q

Which dopaminergic agonist should be used if fertility is the goal?

A

Bromocriptine

67
Q

What are some side effects of cabergoline?

A

-cardiac valve regurgitation in patients treated with high dose cabergoline for Parkinson’s disease or movement disorders. The dose associated with these problems was 3 mg/d, more than 20 times the dose used in hyperprolactinemic patients which is 0.25 mg/d.

68
Q

_______ = an alternative to dopamine-agonist therapy when pregnancy is not desired.

A

Oral contraceptives

69
Q

What are the 3 benifits of using oral contraceptives to treat microadenomas?

A
  1. regular periods
  2. birth control
  3. prevention of osteoporosis
70
Q

What do you treat macroadenomas with initially?

A

Bromocriptine or cabergoline

71
Q

In what patients is surgery reserved for with macroadenomas?

A

very large tumors, patients in whom fertility is desired (the tumor may grow during pregnancy), and patients with rapidly progressing visual loss or symptoms refractory to medical therapy

72
Q

______ is sometimes considered in patients with macroadenomas who poorly tolerate dopamine-agonist therapy or desire definitive treatment.

A

Radiation therapy

73
Q

What are the indications that the patient needs to be referred to an endocrinologist?

A

pt with macroadenoma, suspected pituitary neoplasm other than prolactinoma , failure to respond to bromocriptine or cabergoline, visual loss, desire to become pregnant

Endocrinology - Chapters (20 decks)

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