TOG: Hyperprolactinaemia and reproductive function Flashcards
What is the main inhibitory factor of prolactin?
dopamine
How long after pregnancy do PRL levels return to normal?
6 months after delivery
how do high levels of PRL lead to infertility?
high PRL results in inhibition of ovulation due to inhibition of LH pulsatility
how does hyperprolactinaemia usually present?
oligo-/amenorrhoea/ infertility/ galactorrhoea
in women with hyperprolactinaemia, in what percentage of cases is ovulation restored after treatment with dopamine agonists?
90%
what percentage of women go on to get pregnant after restoring ovulation in women with hyperprolactinaemia?
80-85%
what is the incidence of hyperprolactinaemia in infertile but ovulatory women?
3.8-11.5%
what are the 4 main causes of hyperprolactinaemia?
- pituitary disease- PRLoma/ cushings/ acromegaly
- hypothalamic disease- tumours/ meningioma/ TB/ irradiation
- medications- neuroleptics/ anti-emetics/ methyldopa, verapamil/ TCA’s/ cimetidine/ estrogens
- other- PCOS/ hypothyroid/ renal failure/ idiopathic/ stress
if levels of PRL are <2000, what is usually the cause of hyperPRL?
disconnection hyperPRL- raised PRL due to disruption of dopaminergic inhibition of pituitary lactotrophs. Cause; non-functioning adenomas
if PRL level >2000, what is the common cause?
PRL-secreting tumours
what percentage of the normal population will have radiological evidence of pituitary adenoma?
10%
when in MRI indicated in raised PRL?
if PRL level>1000 with clinical / biochemical effects of pituitary disease
in what percentage of women taking bromocriptine for hyperPRL, is ovulation restored?
in what % cases does bromocriptine reduce size of PRLoma?
80-90% ovulation restored
in 70% cases PRL is reduced in size
what are the side effects of bromocriptine?
nausea, vomiting, postural hypotension
why is cabergoline preferred over bromocriptine for treating hyperPRL?
more effective than bromocriptine in lowering lipid levels.
fewer side effects.
given 1-2x/week
what is the main adverse effect of cabergoline if taken long term?
cardiac valvular insufficiency
what advice is given to people taking cabergoline long term, with regards to their heart?
6-12 monthly cardiac echo for ppl taking cabergoline
in what percentage of women does ovulation resume with taking cabergoline for hyperprolactinaemia?
In what percentage of cases is tumour size reduced?
95%- return of ovulation
tumour reduced in 80% cases
what are the indications for surgery in hyperprolactinaemia?
- failed medical therapy
- expanding PRLoma with ophthalmological/ neurological defecit, not repsonding to medical Tx
- pituitary apoplexy- infarction/haemorrhage into PRLoma
In what percentage of cases is surgery successful for macro and micro PRLomas?
microprolactinoma= 75% macroprolactinoma= 34-38%
what is the first line treatment for women with hyperprolactinaemia who wish to become pregnant?
bromocriptine
what is the risk of clinically sig increase in size of microPRLoma in pregnancy?
2.6%
what is the risk of clinically sig increase in size of MACROPRLoma in pregnancy?
what percentage of these will require surgery?
30-35%.
8.5% of these will require surgery
if woman has been taking bromocriptine prior to pregnancy for microprolactinoma, what advice is given with regards to the medication and further management?
stop bromocriptine early in pregnancy, most have very low risk of tumour expansion.
MRI is done if woman develops visual symptoms of mass expansion
what advice is given to women with macroprolactinomas who become pregnanct?
carry on with medical treatment throughout pregnancy, monitor visual fields each trimester
