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Year 3 - Met3b > Hyperprolactinaemia and hypopituitarism > Flashcards

Hyperprolactinaemia and hypopituitarism Flashcards

1
Q

What is the most common hormonal disturbance of the pituitary

A
  • Hyperprolactinaemia
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2
Q

What does prolactin stimulate

A
  • Prolactin stimulates lactation
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3
Q

What can raised level of prolactin lead to and why

A
  • hypogonadism
  • infertility
  • osteoporosis

does this by inhibiting secretion of GnRH and this reduces LH/FSH and reduction in testosterone or oestrogen

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4
Q

what can inhibit prolactin

A

PRL is secreted from the anterior pituitary and release is inhibited by dopamine from the hypothalamus

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5
Q

Define hyperprolactinaemia

A

> 390mU/L

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6
Q

What are the causes of hyperprolactinaemia

A
  1. excess production from the pituitary - prolactinoma
  2. loss of inhibition by dopamine
    - stalk compression - pituitary adenoma
    - stalk damage - surgery, trauma
    - hypothalamic disease - craniopharyngioma and other tumours
  3. use of dopamine antagonists (most common cause) - metoclopramide, haloperidol, methyldopa, oestrogen’s, ecstasy/MDMA, antipsychotics
  4. physiological - pregnancy, breastfeeding, stress, post-orgasm
  5. other - hypothyrdoism
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7
Q

What are the female symptoms of hyperprolactinaemia

A
  • Amenorrhoea
  • infertility
  • galactorrhea
  • loss of libido
  • weight gain
  • dry vagina
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8
Q

What are the male symptoms of hyperprolactinaemia

A
  • ED
  • reduced facial hair
  • galactorrhea
  • may present late: osteoporosis, local pressure effects from the tumour
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9
Q

What are the pressure effects of hyperprolactinaemia

A
  • decreased acuity
  • hemianopia
  • diplopia
  • ophthalmoplegia
  • optic atrophy
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10
Q

what investigations do you use for a hyperprolactinaemia

A
  • Basal PRL - non stressful venepuncture between 09:00-16:00 hours
  • pregnancy test, TFT, U&Es
  • MRI pituitary - if all other causes are ruled out
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11
Q

How do you manage hyperprolactinaemia

A
  • dopamine agonists

- trans-sphenoidal surgery

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12
Q

Name some dopamine agonists

A
  • Bromocriptine

- cabergoline

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13
Q

describe the management of microprolactinomas

A
  1. Dopamine agonist – bromocriptine, cabergoline
    - Reduce PRL, restore menstrual cycles and decrease tumour size
    - Dose is titrated up: 1.25mg/d PO increase weekly by 1.25-2.5mg/d until ~2.5mg/12h
    - Cabergoline more effective and less SEs but less data on safety in pregnancy
  2. Trans-sphenoidal surgery – if intolerant to dopamine agonists
    - High success rate but carries risks of permanent hormone deficiency and prolactinoma recurrence, and so it is usually reserved as 2nd line treatment
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14
Q

What are the side effects of microprolactinomas

A

SEs – nausea, depression, postural hypotension

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15
Q

What is the difference between microprolactinomas and macroprolactinomas

A
  • Microprolactinomas = <10mm

- Macroprolactinomas = >10mm

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16
Q

how do you manage macroprolactinoma

A
  1. Dopamine agonist – bromocriptine, cabergoline
  2. Trans-sphenoidal surgery
    - Rarely needed but consider if visual symptoms or pressure effects which fail to respond to treatment
    - Bromocriptine ± radiotherapy may be required post-op as complete surgical resection is uncommon
17
Q

what is hypopituitarism

A
  • decreased secretion ofanterior pituitary hormones

- affected in the following order: GH, FSH&LH, TSH, ACTH, PRL

18
Q

What is panhypopituitarism

A
  • this is deficiency of all anterior hormones usually caused by irradiation, surgery or pituitary tumour
19
Q

What are the causes of hypopituitarism

A
  1. Hypothalamus – Kallman’s syndrome, tumour, inflammation, infection (meningitis, TB), ischaemia
  2. Pituitary stalk – trauma, surgery, mass lesion (craniopharyngioma), meningioma, carotid artery aneurysm
  3. Pituitary – tumour, irradiation, inflammation, autoimmunity, infiltration (haemochromatosis, amyloid, metastases), ischaemia (pituitary apoplexy, DIC, Sheehan’s syndrome)
20
Q

what are the symptoms of hypopituitarism

A
  1. GH – central obesity, atherosclerosis, dry wrinkly skin, ↓strength, ↓balance, ↓well-being, ↓exercise ability, ↓CO, osteoporosis, ↓glucose
  2. FSH&LH
    - Women: oligomenorrhoea or amenorrhoea, ↓fertility, loss of libido, osteoporosis, breast atrophy, dyspareunia
    - Men: ED, loss of libido, ↓muscle bulk, hypogonadism (↓body hair, small testes, ↓ejaculate volume, ↓spermatogenesis)
  3. TSH – as for hypothyroidism
  4. ACTH – as for adrenal insufficiency (note no skin pigmentation as ↓ACTH
  5. PRL – rare; absent lactation
21
Q

What do blood tests show in hypopituitarism

A
  • LH and FSH ↓ or ↔
  • Testosterone or oestradiol ↓
  • TSH (↓ or ↔) and T4 ↓
  • PRL ↑
  • IGF-1 ↓
  • Cortisol ↓
  • U&Es – ↓Na+ from dilution
  • FBC – ↓Hb (normochromic, normocytic)
22
Q

what do dynamic tests show in hypopituitarism

A
  1. Short Synacthen test – to assess adrenal axis
  2. Insulin tolerance test (ITT) – to assess adrenal and GH axes
    - CI: epilepsy, heart disease, adrenal failure 🡪 glucagon stimulation test
    - Induces hypoglycaemia, causing stress to ↑cortisol and GH
  3. Arginine + GHRH test
23
Q

What is the management of hypopituitarism

A

Hormone replacement therapy and treatment of underlying cause

  • hydrocortisone - fro secondary adrenal failure before any other hormones are given
  • Thyroxine - if hypothyroid

Hypogonadism

  • men - testosterone enanthate 250mg IM every 3 weeks, daily topical gels, buccal mucoadhesive tablets or patches
  • Women - oestrogen: transdermal estradiol patches or COCP, +/- testosterone or dehydroepiandrosterone
  • gonadotrophin therapy to induce fertility
  • GH - somatotrophin mimics human GH, addresses problems of increased fat mass, decreased bone mass, decreased muscle bulk, decreased exercise capacity and problems with heat intolerance

Year 3 - Met3b (26 decks)

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