Pituitary Disorders Hyperprolactinemia to End

What are the symptoms of metastatic disease in the pituitary?

-in only 7% of patients •Diabetes insipidus •Visual field defects •Anterior pituitary hormonal deficiencies dysfunction •Retroorbital pain and ophthalmoplegia •Poor prognosis

What is seen in physical exam of patients with hyperprolactinemia?

HX: meds, recreational drug/supplements, reproductive fxn PE: galactorrhea, gynecomastia, neuro exam

What is the treatment for hypopituitarism?

directed at cause individualized hormone replacement

What are some malignant pituitary masses?

germ cell tumor sarcoma chordoma pituitary carcinoma metastic: 1-2% of sellar masses -breast cancer in women -lung cancer in men

What is the epidemiology of hyperprolactinemia?

•1% of general population with mild hyperprolactinemia-and will probably be asymptomatic •75% of pts with amenorrhea and galactorrhea have hyperprolactinemia •Most common pathologic cause of amenorrhea in pre-menopausal women •Most common pituitary hormone hypersecretion syndrome in men and women

How is hypopituitarism diagnosed?

•8 AM cortisol level, TSH, free T4, IGF-I, testosterone in men, assess menstrual cycles in women, PRL level •Provocative tests for GH and ACTH deficiency

What is the patient education for hyperprolactinemia>?

•A decrease in prolactin levels may restore ovulation •Advice about birth control methods should be given when prolactin levels approach the normal range

What are the complications that can occur with hyperprolactinemia?

•Blindness •hemorrhage •osteoporosis •infertility

What is hypopituitarism?

•Clinical syndrome of deficiency in pituitary hormone production. •This may result from disorders involving the pituitary gland, hypothalamus, or surrounding structures. •Panhypopituitarism refers to involvement of all pituitary hormones •If only 1 or more pituitary hormones are often involved, resulting in isolated or partial hypopituitarism

What are the specific treatments for prolactinomas/hyperprolactinemia??

•Dopamine agonists (bromocriptine, cabergoline-both ERGOT derivatives) 1ST line of tx •Trans-Sphenoid Resection •Radiation

what is hyperprolactinemia?

•Elevated Serum Prolactin (PRL) •Unique among pituitary hormones, the central control mostly inhibitory (by dopamine) Prolactin: induces and maintains lactation and decrease reproductive function and drive (↓GnRH)

What are the labs done for hyperprolactinemia??

•Fasting prolactin •If elevated exclude non-neoplastic reasons •Pregnancy/Hypothyroidism/Medications •TFTS •LFTs •Cre •HCG •IGF-1 (if clinically indicated) •MRI with/without gad of pituitary

What is the follow up like for patients with hyperprolactinemia?

•Fasting prolactin levels should be monitored monthly •Later, prolactin levels can be monitored every 3-6 months Shrinkage of the tumor should be followed by formal visual-field testing and MRI

What are the structural signs/symptoms of hypopituitarism?

•Headaches, double-vision, or visual-field deficits •Polydipsia/polyuria, Rarely, SIADH

What are the signs and symptoms of hyperprolactinemia in men?

•Hypogonadism, •Decreased libido, •Erectile dysfunction, •Infertility •Sometimes gynecomastia •Sometimes galactorrhea

What is the etiology of galactorrhea?

•Identified cause 50% of the time •Most common pathologic cause: •Hyperprolactinemia

What are the signs and symptoms of hyperprolactinemia in women?

•Menstrual changes (amenorrhea, oligomenorrhea), •Galactorrhea •Infertility Most commonly presents at younger age, always consider in females with nipple discharge

What are the metastatic diseases of the pituitary?

•Metastases to the pituitary and hypothalamus •Accounts for 1-2% of sellar masses Most common with breast cancer in women and lung cancer in men (can be seen with many other cancers)

What is the cause of hypopituitarism?

•Neoplastic (Most common), genetic, congenital, traumatic, vascular, infectious

What is galactorrhea?

•Nipple discharge unrelated to the normal milk production of breast-feeding •Galactorrhea isn't a disease, but sign •It usually occurs in women •It can happen in Nulliparous or menopause states •It can occur in men and infants

What are the goals for dopamine agonist therapy in patients with hyperprolactinemia?

•Normalize prolactin levels and achieve remission of associated symptoms •Reduce or stabilize tumor size, thereby preserving or restoring anterior pituitary function •Prevent disease progression

What are the signs and symptoms of galactorrhea?

•Nulliparous status •Associated with amenorrhea, headache, visual field abnormalities, or other signs of systemic disease •Must do cancer workup if associated with *blood*

What is the pathophysiology of hyperprolactinemia?

•Prolactin is mildly increased by TRH/estrogens •Neurogenically increased with suckling/seizures •High prolactin suppresses GNrH to decrease FSH/LH

What is the etiology of hyperprolactinemia?

•Prolactin secreting pituitary adenoma •Medications: Haldol, Elavil, SSRIs, Opiates..... •Pituitary stalk damage: tumors, granulomas, trauma, radiation •Primary hypothyroidism •Renal failure

What are the causes of hyperprolactinemia?

•Prolactinoma •Acromegaly •Other pituitary tumors •Infiltrative disorders •Hypothalamic and pituitary stalk disease or damage •Primary hypothyroidism •Seizures •PCO •Neurogenic causes (chest wall trauma, herpes zoster) •Renal insufficiency Cirrhosis

What is the epidemiology of hypopituitarism?

•Rare disorder affecting less than 200,000 individuals in the United States. Internationally incidence of 4.2 cases per 100,000 per year and an estimated prevalence of 45.5 cases per 100,000 without gender difference

What are the hormonal signs/symptoms of hypopituitarism?

•Varies from asymptomatic to acute collapse, depending on the etiology, rapidity of onset, and predominant hormones involved •ACTH deficiency - Adrenal (cortisol) insufficiency •TSH deficiency •GH deficiency •ADH deficiency

What are the indications for surgery on prolactinomas?

•Visual field defects unresponsive to medical therapy •Macroadenomas unresponsive to medical therapy •Tumor growth while on medical therapy •Intolerance to dopamine agonist therapy •Pituitary apoplexy (rare) •Cerebrospinal rhinorrhea due to prolactinoma erosion into sphenoid sinus (rare)

What is the prognosis of patients with hyperprolactinemia?

•microadenomas remained stable or gradually decreased prolactin secretion. •One third of patients with idiopathic hyperprolactinemia may experience resolution without treatment. •Surgery is often not curative for macroprolactinomas, •Recurrence rates of hyperprolactinemia are as high as 80%, -patients require long-term medical therapy.