Hyperprolactinemia: pathophysiology and therapeutic approach

Drug-associated hyperprolactinemia: A comprehensive disproportionality analysis based on the FAERS database

Hyperprolactinemia (HPRL) is a clinically significant adverse event that requires careful monitoring. This study aims to identify the medications associated with HPRL using data from the FDA Adverse Event Reporting System (FAERS) between 2004Q1 and 2024Q1. Disproportionality analysis was performed to identify potential drug signals. Sensitivity analysis was conducted to assess the stability and strength of HPRL signals associated with these medications, as well as to examine signal differences by age and gender through stratification. Time-to-onset (TTO) analysis was performed to investigate the factors affecting the onset of HPRL. Disproportionality analyses identified 39 drugs related to HPRL across six main anatomical systems, with the majority (N = 29) affecting the nervous system. Notably, most of these medications belong to psychotropic categories, including atypical antipsychotics (AAPs, N = 13), typical antipsychotics (TAPs, N = 5) and selective serotonin reuptake inhibitors (SSRIs, N = 5). Sensitivity analysis indicated that most signals remained robust, with risperidone exhibiting the strongest signal for HPRL, followed by amisulpride, paliperidone, fluphenazine, and thioridazine. Stratified analysis showed that females had stronger signals for HPRL. Compared to individuals aged 18-44, those aged ≥45 exhibited weaker signals, while the signals in minors varied by drug. TTO analysis revealed that AAP-related HPRL manifested earlier in females, with earlier onset observed in minors using AAPs or SSRIs. In conclusion, we identified and ranked drugs associated with HPRL, primarily psychotropic medications, and observed variations in signal strength and onset time across gender and age. These findings emphasize the importance of individualized HPRL screening based on specific medications, gender, and age.

Antipsychotic-induced hyperprolactinemia: Toxicologic mechanism and the increased breast cancer risk

Antipsychotic drugs are effective at improving both the positive and negative symptoms of schizophrenia as well as the manic phase of bipolar disorder. Whether an antipsychotic is termed typical or atypical is related to the xenobiotic's propensity to cause extrapyramidal side effects. However, with a few exceptions, drugs of both classes of antipsychotics are known to cause hyperprolactinemia. As many breast cancers are responsive to prolactin concentrations, the persistent increase in prolactin of the antipsychotics has implications for public health and carcinogenesis. The objective of this study was to review the extant literature on hyperprolactinemia due to antipsychotics, and to determine the risk imposed by those drugs on human breast cancer. A summary risk of breast cancer with use of any antipsychotic was found to be 1.19 (95 % confidence interval 1.10-1.30). When limiting usage of antipsychotics to 5 or more years, the summary risk increased to 1.26 (95 % confidence interval 1.12-1.43). And when limited to those studies who evaluated only those medications with the greatest increase in prolactin, the risk increased to 1.59 (95 % confidence interval 1.37-1.85). Given this increased risk of breast cancer, stronger warnings about this increased risk are warranted, and regular monitoring of prolactin levels and breast cancer screening should be part of the management plan for these patients.

Ischemic stroke risk in patients with dopamine agonist-treated hyperprolactinemia

Data on the risk of stroke in patients with hyperprolactinemia are limited. This study aimed to evaluate the association between hyperprolactinemia and ischemic stroke in a large cohort and identify predictors of stroke in this population. This was a retrospective cohort study comparing the incidence of ischemic stroke in patients with dopamine agonist-treated hyperprolactinemia to matched controls in a 1:5 ratio. The primary outcome was the diagnosis of ischemic stroke. The cohort included 2440 patients with DA-treated hyperprolactinemia patients (mean age ± SD: 38.42 ± 14.57 years, 60.2% women) matched to 12,022 controls (mean age ± SD: 38.15 ± 14.36 years, 60.8% women). Ischemic stroke occurred in 195 patients with hyperprolactinemia (8.0%) and 747 controls (6.21%) (adjusted HR 1.24, 95% CI 1.06-1.46). Patients with hyperprolactinemia developed stroke at a younger age (57.75 ± 15.88 years vs. 60.18 ± 15.20 years, p = .05). Patients with PRL levels >5× ULN at diagnosis had a higher stroke incidence than those with lower levels (9.73% vs. 6.85%; HR 1.48, 95% CI 1.11-1.97). Longer time to prolactin normalization was associated with a higher incidence of stroke (median 21.88 vs. 13.78 months; p = .0005). In multivariate analysis, age ≥60 years, male gender, hypertension, type 1 or type 2 diabetes mellitus, and ischemic heart disease were significant predictors of stroke in patients with hyperprolactinemia. Dopamine agonist-treated hyperprolactinemia is associated with an increased risk of ischemic stroke compared to well-matched controls from the general population. Higher prolactin levels at diagnosis and a longer time to normalization were linked to a greater risk of stroke.

Prolactin protects hippocampal neurons against H2O2-induced neurotoxicity by suppressing BAX and NOX4 via the NF-κB signaling pathway

Reactive oxygen species (ROS) are physiological byproducts of neuronal metabolism. However, an imbalance between ROS generation and antioxidant capacity, often driven by dysregulated pro-oxidant enzymes like nicotinamide adenine dinucleotide phosphate oxidases (NOX), can result in deleterious oxidative stress. This oxidative stress is a critical factor in the pathogenesis of neurodegenerative diseases. While interventions with broad-spectrum antioxidants have demonstrated limited efficacy, the modulation of endogenous antioxidant mechanisms presents a promising therapeutic avenue. Here, we investigated the potential of the neuroprotective hormone prolactin to mitigate oxidative stress and subsequent neuronal cell death. Prolactin protected primary mouse hippocampal neurons from hydrogen peroxide (H2O2)-induced oxidative damage. Prolactin reduced ROS levels, lipid peroxidation, and apoptosis, and its effects were occluded by a specific prolactin receptor antagonist (G129R-hPRL). Mechanistically, prolactin suppressed H2O2-induced mRNA upregulation of pro-oxidative Nox4 and pro-apoptotic Bax. Moreover, prolactin induced nuclear factor kappa B (NF-κB) nuclear translocation, and the inhibition of the NF-κB signaling pathway abolished the neuroprotective and transcriptional effects of prolactin, indicating its central role in prolactin-mediated protection. Our findings indicate that prolactin exerts potent antioxidant and neuroprotective effects by modulating the expression of Nox4 and Bax, thereby reducing ROS generation and neuronal apoptosis. This study underscores the therapeutic potential of prolactin in attenuating oxidative stress and suggests a possible role in the treatment of neurodegenerative diseases.

Vitex agnus castus Extract Ze 440: Diterpene and Triterpene's Interactions with Dopamine D2 Receptor

Pre-clinical studies suggest that extracts prepared from the fruits of Vitex agnus castus (VAC) interact with dopamine D2 receptors, leading to reduced prolactin secretion. In previous experiments, dopaminergic activity was mostly evaluated using radioligand binding assays or via the inhibition of prolactin release from rat pituitary cells. Diterpenes featuring a clerodadienol scaffold were identified as major active compounds, but no conclusive data regarding their potency and intrinsic activity are available. Utilising advances in chromatography, we re-examined this topic using HPLC-based tracking of bioactivity via microfractionation of the VAC extract Ze 440. Using a cAMP-based assay, we measured dopaminergic activity in CHO-K1 cells that overexpress the human D2 receptor. Six diterpenes were isolated from two active HPLC microfractions. Viteagnusin I emerged as the most potent diterpene (EC50: 6.6 µM), followed by rotundifuran (EC50: 12.8 µM), whereas vitexilactone was inactive (EC50: >50 µM). Interestingly, triterpenes were also identified as active, with 3-epi-maslinic acid being the most active compound (EC50: 5.1 µM). To better understand these interactions at the molecular level, selected diterpenes and triterpenes were analysed through molecular docking against D2 receptor structures. Our data show that the dopaminergic activity of VAC diterpenes seems to depend on the configuration and on ring substitution in the side chain. This study also highlights for the first time the dopaminergic contribution of triterpenes such as 3-epi-maslinic acid.

Efficacy of Metformin-Cabergoline Compared to Metformin Monotherapy for Management of PCOS With Hyperprolactinemia: A Systematic Review and Meta-analysis

Background

Metformin plays a major part in the treatment of polycystic ovarian syndrome .Trials are being conducted to compare the effectiveness of combination of metformin with cabergoline in the treatment of hyperprolactinemia and polycystic ovarian syndrome.

Objectives

The purpose of this study is to compare the effectiveness of metformin monotherapy and combination therapy with cabergoline versus metformin for the management of polycystic ovarian syndrome with hyperprolactinemia.

Methodology

An extensive search up until 31 May 2024 of electronic databases (PubMed, Registry of Controlled Clinical Trials, Web of Sciences, SCOPUS) to find pertinent studies. An analysis was conducted with both observational data and randomized clinical trials . To compute the standard mean difference, weighted mean difference, odds ratio, and 95% confidence interval, RevMan (v5.3) was utilized. Primary outcomes that were assessed included body-mass index, regular menstruation, weight change, prolactin, testosterone, and dehydroepiandrosterone-sulfate levels.

Results

Three randomized controlled trials and 1 observational study, taking a total patient population of n = 535, were part of our final analysis. Prolactin (SMD = -3.23 95% CI: (-4.90, -1.55)) and dehydroepiandrosterone-sulfate levels (SMD = -0.27 95% CI: (-0.52, -0.01)) were significantly lower in the metformin and cabergoline combination therapy group; monthly regularity was also significantly higher (OR = 3.07 95% CI: (2.09, 4.51)). Statistically, there was no significant difference in weight, body-mass index, or testosterone levels.

Conclusions

In the treatment of polycystic ovarian syndrome, the combination of metformin and cabergoline significantly lowers prolactin levels and encourages regular menstrual cycles. Although metformin has the potential to suppress testosterone levels, more investigation is required to determine how combination therapy affect dehydroepiandrosterone-sulfate and testosterone levels. It's interesting to note that while neither intervention had a substantial impact on weight or body-mass index, metformin and cabergoline combination therapy outperformed metformin monotherapy in terms of supporting regular menstrual cycles. Customized therapy approaches are essential, and large-scale trials involving a variety of groups are required to comprehend the safety and effectiveness of treatments.

Determination of the frequency of hyperprolactinemia-related etiologies and the etiology-specific mean prolactin levels

BACKGROUND

Prolactin (PRL) is a peptide hormone secreted by the anterior pituitary that provides lactation during the postpartum period. The causes of hyperprolactinemia are pituitary tumors, medications, primary hypothyroidism, polycystic ovary syndrome (PCOS), renal failure, idiopathic, and other physiological causes such as pregnancy and lactation. In this study, we aimed to investigate the prevalence of hyperprolactinemia etiologies and the mean/median prolactin levels in different etiologies.

METHODS

The patients admitted to our outpatient clinic between January 2009-December 2019 were retrospectively screened from our hospital database with ICD-10 codes. Four hundred patients were included in the study; 69.5% of the patients were women. Their mean age was 43.67±13.42 years, the duration of illness was 7.8±5.6 years. The most frequent causes of hyperprolactinemia were found as follows: 52.5% (N.=210) prolactinoma, 7% (N.=28) gonadotropinoma, 6.5% (N.=26) drug-related, 6.5% (N.=25) PCOS, 5.8% (N.=23) idiopathic, 5% (N.=20) acromegaly, 4.8% (N.=19) nonfunctioning adenoma 2.3% (N.=9) craniopharyngioma. Patients with gonodotropinoma were significantly older, and the patients with PCOS were significantly younger than the patients with hyperprolactinemia due to the other etiologies. Patients with prolactinoma had significantly higher prolactin levels and longer duration of the illness when compared to other etiologies of hyperprolactinemia (168.00* ng/mL [14-23,500] [168]); 8* years (0-39) (5.00) years respectively, *median values, (min-max levels) and (interquartile range), respectively.

RESULTS

There was no significant difference between prolactin levels of other etiologic groups except prolactinoma. Surprisingly, we found PCOS patients with prolactin levels greater than 100 ng/mL and acromegaly or drug-induced hyperprolactinemia with prolactin levels greater than 200 ng/mL. In our study, unlike the literature, macroprolactinemia can be seen alone or together with other pathologies. Except for macroprolactinoma, it is not possible to diagnose according to prolactin level. Similar to the literature, prolactinoma was the most common cause of hyperprolactinemia. The causes of hyperprolactinemia, in order of decreasing frequency, were determined to be gonodotropinoma, drug-related, PCOS, idiopathic, and acromegaly. The range of prolactin detected in PCOS is given as new information. It was found that the pediatric group and the adult group had a similar etiology and PRL level.

CONCLUSIONS

A large spectrum of physiologic/pathologic conditions increases the prolactin levels, and prolactin levels may vary from person to person. So, the serum prolactin level alone does not guide a clinical diagnosis or make a differential diagnosis.

20-Week intramuscular toxicity study of rotigotine behenate extended-release microspheres for injection via intramuscular injection in cynomolgus monkeys

Continuous dopaminergic stimulation (CDS) has become an important strategy for the development of drugs to treat Parkinson's disease (PD). Rotigotine behenate extended-release microspheres (RBEM) for injection represents a new treatment regime for CDS and is being applied for clinical trial. Our study in cynomolgus monkeys was a 20-week repeat dose toxicity investigation with RBEM at dosages of 90, 180, 360, with a 12-week recovery period. The results observed some irritations in the application site and surrounding tissues in Placebo microspheres and each dose of RBEM, was accompanied with increased white blood count and fibrinogen. RBEM-treated monkeys were additionally noted with a pharmacological action-related decrease in prolactin. These findings showed certain reversibility after the 12-week recovery phase. No clear sex difference was noted in the plasma exposure to rotigotine. The exposure generally increased in a dose-proportional manner. In summary, major toxicological effects are associated with the dopamine agonist-related properties of rotigotine, and the removal of foreign bodies caused by p oly (lactide-co-glycolide) (PLGA)and sodium carboxymethyl cellulose (SCMC), and the no-observed-adverse-effect-level (NOAEL) was 360 mg/kg.

Comparative efficacy of metformin combined with cabergoline versus metformin alone in patients with PCOS and hyperprolactinemia: A systematic review and meta-analysis of randomized controlled trials

Isntroduction. Polycystic ovary syndrome (PCOS) is a multifaceted endocrine-gynecological condition affecting a substantial number of women during their reproductive years. Metformin (MET) has been shown to improve ovarian function in PCOS-related conditions, while cabergoline is recognized for its powerful and sustained ability to reduce prolactin levels. This study investigates the potential impact of combining cabergoline with metformin while comparing it with metformin alone in the treatment of PCOS alongside hyperprolactinemia.

METHOD

To gather data, we searched PubMed, Google Scholar, ScienceDirect, and Cochrane Central. Eligible studies were randomized controlled trials involving patients with PCOS and hyperprolactinemia. Outcome measures included changes in the levels of prolactin, testosterone, DHEAS, BMI and menstrual irregularities. RevMan version 5.4 was used to analyze outcomes.

RESULT

This study incorporated three Randomized Controlled Trials (RCTs) involving 405 participants in total. Patients receiving a combination of metformin and cabergoline experienced significant reductions in prolactin and testosterone levels (p= <0.0001 and p=<0.0001, respectively). Conversely, alterations in DHEAS levels and BMI did not reach statistical significance (p = 0.19 and p = 0.71, respectively). Notably, women solely prescribed metformin exhibited significantly higher rates of menstrual irregularities compared to those receiving both metformin and cabergoline (p=<0.0001).

CONCLUSION

Our analysis underscores the synergistic effect achieved by pairing metformin and cabergoline in patients with PCOS and hyperprolactinemia. However, we encountered only a restricted number of studies meeting our criteria. It is imperative to consistently assess the combined effects of metformin and cabergoline to gain deeper insights into their effectiveness in addressing PCOS and hyperprolactinemia.

Determinants of menstrual dysfunction in the female athlete triad: A cross-sectional study in Italian athletes

BACKGROUND

In 1992 the American College of Sports Medicine first described the Female Athlete Triad. The Triad is a metabolic injury involving three distinct clinical traits: low energy availability, with possible eating disorder, low bone mineral density and menstrual dysfunction (MD). Although the estimated prevalence of the Triad is low (1.2 %), single factors are common in female athletes, at all competitive levels and ages. Even though the Triad was described over two decades ago, the interrelation of the three diagnostics components is still debated: additional evidence is required to improve the multidisciplinary treatment approach for this complex condition. MD is one of the first signs of energy impairment. The present study aims at investigating MD determinants and predictors in female athletes, to allow an early diagnosis of the Triad and to implement adequate preventive strategies.

MATERIALS AND METHODS

An original structured questionnaire was composed to detect the presence of MD risk factors. Included participants were active female athletes within reproductive age range (15-40 years old). Anthropometric parameters and training-related factors, possibly affecting the regularity of the menstrual cycle, were investigated.

RESULTS

Respondents were 288 female athletes. Among them, 73.3 % were under 25 years of age; 6.6 % resulted underweight; 30.6 % reported to follow a meal plan/diet and 13.9 % declared to be a smoker. Lean sports were practiced by 30.6 % of responders. Body-weight congruence was detected in in 79.9 % of participants, whereas overestimation of body image was found in 16.3 % of athletes. Irregular menstrual cycle, a possible MD predictor, was present in 33.0 % of athletes, with 41.1 % practicing some lean sport (p = 0.007). Also, overestimation of body image suggested an increased risk of menstrual irregularity (p = 0.001). BMI <18.5 or BMI >30 could also act as risk factor, although significance was not fully obtained (p = 0.053). Overall, practice of lean sports and overestimation of body image appeared good determinants of increased menstrual irregularity (AOR 2.02 and 3.83, respectively).

CONCLUSIONS

Menstrual irregularity in female athletes can be considered an early predictor of MD: risk is further increased in athletes of lean sports and reporting an overestimation of self-perceived body image. Screenings and awareness programs should specifically address female athletes, because of their vulnerable-group profile. In order to define a standardized at-risk profile for Triad onset and sequelae likelihood, evaluation of menstrual regularity should especially be considered, in conjunction with the assessment of other indicators of energy availability (e.g. TEE, lean and fat mass, BMC). Testing for sport-derived stress and disordered eating attitudes is also recommended. Preventive strategy should involve the proactive engagement of sport clubs and periodic competitive sport medical assessment.

Clinical Impact of New Reference Intervals for the Roche Prolactin II Immunoassay

Context

The Roche prolactin immunoassay is used throughout the world. It reports higher values than the Siemens immunoassay but the manufacturer-defined reference intervals are similar. Patient results are often above the Roche upper limit but within the Siemens interval, causing diagnostic confusion.

Objective

Establish new reference intervals for the Roche and Siemens prolactin immunoassays.

Methods

We established new reference intervals for the Roche and Siemens immunoassays using 374 specimens from healthy outpatients. We performed chart review for unnecessary testing and treatment for 298 patients in a 6-month period with at least 1 Roche prolactin value above the manufacturer-defined upper limit and below our new upper limit.

Results

The new upper limit for the Roche assay was 37.8 ng/mL (females) and 22.8 ng/mL (males). The manufacturer-defined limits were 23.3 ng/mL and 15.2 ng/mL, respectively. New intervals for the Siemens assay matched the manufacturer. No cases of clinically significant pathophysiologic prolactin excess were identified in patients with values between the manufacturer-defined upper reference limit and our new Roche upper limit. Unnecessary further evaluation in these patients included 459 repeat prolactin measurements, 57 macroprolactin measurements, 39 magnetic resonance imaging studies, and 28 endocrine referrals. Eleven patients received dopamine agonists. The minimum cost of excess care using Medicare reimbursement rates was $34 134, with substantially higher amounts billed to patients and their insurance providers.

Conclusion

Adoption of new upper reference limits for the Roche prolactin assay of 37.8 ng/mL (females) and 22.8 ng/mL (males) would not delay diagnosis or necessary intervention in patients with clinically significant pituitary tumors but would reduce unnecessary evaluation in patients without pathophysiologic prolactin excess.

Treatment of hyperprolactinemia in women: A Position Statement from the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and the Brazilian Society of Endocrinology and Metabolism (SBEM)

Dopamine agonists are the first line of treatment for patients with symptomatic hyperprolactinemia due to prolactinomas and in those with idiopathic hyperprolactinemia. Treatment with these agents is effective in 80%-90% of the cases. Infertility treatment of patients with hyperprolactinemia is also carried out with dopamine agonists, aiming for the normalization of prolactin levels. The risk of symptomatic growth of prolactinomas during pregnancy is dependent on the tumor's size, duration of previous treatments, and prolactin levels. Notably, the corresponding risk is relatively low in cases of microprolactinomas (<5%). Remission of hyperprolactinemia occurs in about 30% of the patients after drug treatment and may also occur after pregnancy and menopause. The use of some drugs, such as antidepressants and antipsychotics, is a frequent cause of hyperprolactinemia, and managing this occurrence involves unique considerations. This position statement by the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and Brazilian Society of Endocrinology and Metabolism (SBEM) addresses the recommendations for measurement of serum prolactin levels and the investigations of symptomatic and asymptomatic hyperprolactinemia and drug-induced hyperprolactinemia in women.

Streamlined Stereoselective Entry to (-)-Quinagolide and to 3-Substituted Octahydrobenzo[g]-Quinolines

A very short stereoselective synthesis of enantiomerically pure (3S, 4aS, 10aR)-quinagolide has been developed. The key steps involved are a copper-catalyzed regioselective arylation of (S)-epichlorohydrin with 1,6-dimethoxynaphthalene and a diastereoselective trans-reduction of a cyclic enamine intermediate. The possibility to use both enantiomers of epichlorohydrin and the diastereodivergency found in the reduction process paves the way for a general preparation also in the nonracemic form of chiral trans-fused 3-substituted octahydrobenzo[g]quinolines that are privileged structures in medicinal chemistry.

Prolactin in Polycystic Ovary Syndrome: Metabolic Effects and Therapeutic Prospects

Polycystic ovary syndrome (PCOS) is the most prevalent endocrine and metabolic disorder in premenopausal women, characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Patients frequently present comorbidities, including obesity, insulin resistance, and impaired glucose and lipid metabolism. The diverse clinical presentation may mimic various endocrine disorders, making the diagnosis challenging in some clinical circumstances. Prolactin (PRL) is a recommended biomarker in the initial diagnostic workup to rule out hyperprolactinemia (HPRL). The traditional role of PRL is linked to lactation and the reproductive system. Recent research highlights PRL's emerging role in metabolic homeostasis. PRL influences metabolism directly by interacting with the pancreas, liver, hypothalamus, and adipose tissue. Its influence on an individual's metabolism is intricately tied to its serum concentration. While deficient and very high levels of PRL can negatively affect metabolism, intermediate-normal to moderately high levels may promote metabolic health. In women with PCOS, PRL levels may be altered. Research results on different aspects of the relationship between PCOS and the impact of various levels of PRL on metabolic homeostasis are limited and inconsistent. In this narrative literature review, we comprehensively examined data on serum PRL levels in PCOS patients. We investigated the correlation between a favorable metabolic profile and serum PRL levels in this population. Furthermore, we explored the concept of beneficial PRL effects on metabolism and discussed the potential therapeutic application of dopamine agonists in PCOS treatment. Lastly, we emphasized several promising avenues for future research in this field.

Population Pharmacokinetic Analysis of Follicle-Stimulating Hormone During Ovarian Stimulation: Relation with Weight, Prolactin and Gene Polymorphism in THADA and ADIPOQ

BACKGROUND

Personalisation strategies of ovarian stimulation for in vitro fertilisation (IVF)/ intracytoplasmic sperm injection (ICSI) treatments using exogenous follicle-stimulating hormone (FSH) have been extensively studied over the past 20 years. This research aimed to develop a FSH population pharmacokinetic (PPK) model taking into account the contribution of gene polymorphisms in Chinese reproductive-age women.

METHODS

Data from 173 patients undergoing GnRH agonist down-regulation long protocols of IVF/ICSI treatment were collected. PPK analysis was subsequently conducted using the nonlinear mixed-effect model (NONMEM) software. Several covariates, including 18 single nucleotide polymorphisms, demographic factors and biological characteristics, were evaluated. The final PPK model was extensively validated using bootstrapping and normalised prediction error distribution, as well as external validation on an independent group of 35 patients.

RESULTS

FSH PPK was accurately described by a one-compartment model with first-order absorption. The typical population value of apparent clearance was estimated to be 0.81 L/h [relative standard errors (RSE) 5.3%] with an inter-individual variability (IIV) of 16.0%. The typical apparent distribution volume was 8.36 L (RSE 9.7%, 59.7% IIV), and the absorption rate constant was estimated to be 0.0444 h-1 (RSE 9.1%). Body weight, basal prolactin concentration and the gene ADIPOQ (rs1501299) showed a significant covariate effect on the FSH clearance rate and exposure concentration. Genotypes of THADA (rs12478601) significantly influenced the distribution volume. Simulation results indicated that patients with the TT genotype of THADA (rs12478601) required a longer time to reach steady state and had less fluctuation in FSH levels. Model evaluations showed that the final model accurately and precisely described the observed data and demonstrated effective prediction performance.

CONCLUSION

PPK models of FSH have been developed, which could potentially be used for FSH dosage individualisation in the clinical setting.

CLINICAL TRIAL REGISTRATION

This study has been registered with the Chinese Clinical Trials Registry (ChiCTR2100049142).

A Literature Review and a Proposed Classification of the Relationships between Ovulatory Infertility and Lifestyle Factors Based on the Three Groups of Ovulation Disorders Classified by WHO

Ovulatory infertility is a serious clinical problem whose direct causes are still largely unknown. In addition to pathologies that make it impossible for a couple to establish a pregnancy, there are a number of other factors that have a bearing on fertility, including lifestyle factors, and particularly diet. Although numerous studies have been performed linking such factors to ovulatory infertility, most of them lack the necessary clinical significance, instead focusing on observational data and suggesting or establishing associative relationships. This article consists of a literature review focusing on connections between lifestyle factors such as diet, physical exercise, oxidative stress, sleep, and supplementation, and ovulatory infertility. Special emphasis was given to issues such as obesity and insulin resistance and their mutual relationship with other factors linked to ovulatory infertility. In addition, based on the conclusions of the literature review, the authors have proposed a classification of relationships between ovulation disorders and lifestyle factors in ovulatory infertility within the framework of the WHO classification of ovulation disorders. Furthermore, areas that merit further research have been indicated as well as those that do not. WHO Group II disorders gained prominence in the results of the study as the number of links with lifestyle factors and ovulatory infertility found in the course of the review greatly exceeded those for Groups I and III. The data presented in the article show that the issues of proper diet and physical exercise are those that could benefit from robust clinical studies focused specifically on ovulation infertility, while studies concerning the relationship between oxidative stress, sleep, and supplementation and ovulatory infertility do not seem to be promising directions as far as clinical significance is concerned.

Identifying a causal link between prolactin signaling pathways and COVID-19 vaccine-induced menstrual changes

COVID-19 vaccines have been instrumental tools in the fight against SARS-CoV-2 helping to reduce disease severity and mortality. At the same time, just like any other therapeutic, COVID-19 vaccines were associated with adverse events. Women have reported menstrual cycle irregularity after receiving COVID-19 vaccines, and this led to renewed fears concerning COVID-19 vaccines and their effects on fertility. Herein we devised an informatics workflow to explore the causal drivers of menstrual cycle irregularity in response to vaccination with mRNA COVID-19 vaccine BNT162b2. Our methods relied on gene expression analysis in response to vaccination, followed by network biology analysis to derive testable hypotheses regarding the causal links between BNT162b2 and menstrual cycle irregularity. Five high-confidence transcription factors were identified as causal drivers of BNT162b2-induced menstrual irregularity, namely: IRF1, STAT1, RelA (p65 NF-kB subunit), STAT2 and IRF3. Furthermore, some biomarkers of menstrual irregularity, including TNF, IL6R, IL6ST, LIF, BIRC3, FGF2, ARHGDIB, RPS3, RHOU, MIF, were identified as topological genes and predicted as causal drivers of menstrual irregularity. Our network-based mechanism reconstruction results indicated that BNT162b2 exerted biological effects similar to those resulting from prolactin signaling. However, these effects were short-lived and didn't raise concerns about long-term infertility issues. This approach can be applied to interrogate the functional links between drugs/vaccines and other side effects.

The Hypothalamic-Pituitary-Gonadal Axis in Men with Schizophrenia

Schizophrenia is a severe mental disorder with a chronic, progressive course. The etiology of this condition is linked to the interactions of multiple genes and environmental factors. The earlier age of onset of schizophrenia, the higher frequency of negative symptoms in the clinical presentation, and the poorer response to antipsychotic treatment in men compared to women suggests the involvement of sex hormones in these processes. This article aims to draw attention to the possible relationship between testosterone and some clinical features in male schizophrenic patients and discuss the complex nature of these phenomena based on data from the literature. PubMed, Web of Science, and Google Scholar databases were searched to select the papers without limiting the time of the publications. Hormone levels in the body are regulated by many organs and systems, and take place through the neuroendocrine, hormonal, neural, and metabolic pathways. Sex hormones play an important role in the development and function of the organism. Besides their impact on secondary sex characteristics, they influence brain development and function, mood, and cognition. In men with schizophrenia, altered testosterone levels were noted. In many cases, evidence from available single studies gave contradictory results. However, it seems that the testosterone level in men affected by schizophrenia may differ depending on the phase of the disease, types of clinical symptoms, and administered therapy. The etiology of testosterone level disturbances may be very complex. Besides the impact of the illness (schizophrenia), stress, and antipsychotic drug-induced hyperprolactinemia, testosterone levels may be influenced by, i.a., obesity, substances of abuse (e.g., ethanol), or liver damage.

Increasing lysergic acid levels for ergot alkaloid biosynthesis: Directing catalysis via the F-G loop of Clavine oxidases

Most ergot alkaloid drugs are semi-synthetically derived from the natural product lysergic acid, a valuable precursor for the development of novel ergot alkaloid drugs. Clavine oxidase (CloA) is a putative cytochrome P450, identified in the ergot alkaloid biosynthesis pathway, and a key enzyme that catalyzes the formation of lysergic acid from the precursor alkaloid agroclavine in a two-step oxidation reaction. We demonstrated in this study that Saccharomyces cerevisiae can be used as a viable host for the functional expression of CloA from Claviceps purpurea and its orthologs. We also showed that CloA orthologs differ in their ability to oxidize the substrate agroclavine, with some orthologs only able to perform the first oxidation reaction to produce elymoclavine. Of particular note, we identified a region between the F-G helices of the enzyme that may be involved in directing oxidation of agroclavine by substrate recognition and uptake. Using this knowledge, engineered CloAs were shown to produce lysergic acid at levels exceeding that of wildtype CloA orthologs; a CloA variant, chimeric AT5 9Hypo CloA, increased production levels of lysergic acid to 15 times higher as compared to the wildtype enzyme, demonstrating future utility for the industrial production of ergot alkaloids using biosynthetic routes.

Osteoporosis and Celiac Disease: Updates and Hidden Pitfalls

Celiac disease (CD) is an autoimmune disorder caused by gluten ingestion in genetically predisposed individuals. In addition to the typical gastrointestinal symptoms (e.g., diarrhea, bloating, and chronic abdominal pain), CD may also present with a broad spectrum of manifestations, including low bone mineral density (BMD) and osteoporosis. The etiopathology of bone lesions in CD is multifactorial and other conditions, rather than mineral and vitamin D malabsorption, may affect skeletal health, especially those related to the endocrine system. Here, we describe CD-induced osteoporosis in an attempt to enlighten new and less-known aspects, such as the influence of the intestinal microbiome and sex-related differences on bone health. This review describes the role of CD in the development of skeletal alterations to provide physicians with an updated overview on this debated topic and to improve the management of osteoporosis in CD.

Treatment for Infertility in Laron Syndrome: A Case Report

Laron syndrome is a rare, genetic, growth hormone insensitivity disorder caused by mutations in the growth hormone receptor gene. Affected patients have severe postnatal growth failure, characteristic facial features, and metabolic abnormalities, including severe obesity and metabolic syndrome. Women with Laron syndrome are usually subfertile, mainly due to obesity and metabolic dysregulation, and require treatment for their chronic reproductive dysfunction. To date, infertility in Laron syndrome patients is a rarely addressed problem and, as a result, adequate data regarding its treatment are lacking. Here we present, for the first time in the literature, a rare case of successful treatment of a young woman with Laron syndrome who suffered from infertility due to hyperprolactinemia.

Sociodemographic and clinical characteristics related with hyperprolactinaemia in psychiatric clinical population

BACKGROUND

Hyperprolactinaemia (HyperPRL) induced by psychotropic drugs is a high-prevalence consequence which has repercussions in psychical and mental health in the psychiatric population, so this research had the objective to expand which sociodemographic and clinical features are associated with prolactin (PRL) elevation in patients treated with antidepressant and/or antipsychotic drugs.

METHODS

An observational, cross-sectional, comparative and retrolective study was conducted on 300 patients who received clinical attention in a third level of psychiatric care unit in Mexico during 2017. These patients have been reported to show PRL levels greater than 25 ng/mL among women and greater than 20 ng/mL among men. In the same way, sociodemographic and clinical variables were collected, as well as psychiatric diagnosis and type of psychopharmacological treatment used by the patients.

RESULTS

HyperPRL was more frequent in women (80.7%) than men (19.3%). The mean levels of PRL were 68.94 ± 62.28 ng/mL with higher levels in women (71.9 ± 67.3, p=.02). Regarding the treatment, 78.3%, 71.3% and 49.7% consumed antipsychotics, antidepressants, and both drugs, respectively. The relationship between hyperPRL (>100 n/mL) and typical antipsychotics was dose-dependent (33.23 ± 13.24 mg, p=.01). In the multivariate regression models according to the type of treatment, as well as the demographic and clinical features, hyperPRL was associated independently with the use of antipsychotic treatment, pituitary adenoma and hypertension (R²=0.05).

CONCLUSIONS

HyperPRL is a complex clinical syndrome frequent in the psychiatric population with detrimental long-term consequences, as well as its relationship with the use of psychotropic drugs as in the case of antipsychotics. Effective actions should be implemented in the prevention, approach and treatment of this condition paying special attention to the accompanying medical comorbidities.

Long-term opioid treatment and endocrine measures in patients with cancer-related pain: a systematic review

OBJECTIVES

Opioid analgesics are the main stay for cancer pain management; however, long-term opioid treatment (L-TOT) may suppress the endocrine system. This systemic review aimed at investigating effects of L-TOT on the endocrine system in patients with cancer-related pain.

METHODS

A search on MEDLINE, EMBASE and Web of Science databases was performed. Inclusion criteria were clinical studies investigating endocrine measures in adult patients with cancer-related pain in L-TOT (≥4 weeks). Outcomes and quality of evidence were assessed.

RESULTS

A total of 252 abstracts were identified; out of which 247 were excluded and five cross-sectional studies were included and analyzed. L-TOT was associated with lower serum concentration levels of total- and free testosterone in males, follicular stimulating hormone in females, and luteinizing hormone in both sexes. Moreover, higher morphine equivalent daily doses (MEDDs) were correlated with higher levels of cortisol and lower levels of LH in both sexes, and lower levels of total- and free testosterone in males. Sexual dysfunction was associated with low sex hormone levels. Level of evidence was low/very low.

CONCLUSIONS

The studies identified demonstrated that patients with cancer-related pain in L-TOT may have gonadal hypofunction causing sexual dysfunction, which may be correlated with opioid dose level. In addition, high serum concentrations of cortisol were positively correlated with high opioid dose levels. However, the evidence was weak and further research is necessary. PROSPERO, ID-number: CRD42020213059.

Metformin in the Treatment of Amisulpride-Induced Hyperprolactinemia: A Clinical Trial

Objective

To evaluate the efficacy and safety of metformin in the treatment of amisulpride-induced hyperprolactinemia.

Methods

A total of 86 schizophrenic patients who developed hyperprolactinemia after taking amisulpride were screened and randomly assigned to the metformin group (42 patients) and placebo group (44 patients) and followed up for eight weeks. The patients’ serum prolactin levels, blood glucose and lipids were measured at the baseline and the end of the intervention. The treatment emergent symptom scale (TESS) was also assessed.

Results

After eight weeks of intervention, serum prolactin levels in the metformin group decreased from (1737.360 ± 626.918) mIU/L at baseline to (1618.625 ± 640.865) mIU/L, whereas serum prolactin levels in the placebo group increased from (2676.470 ± 1269.234) mIU/L at baseline to (2860.933 ± 1317.376) mIU/L. There was a significant difference in prolactin changes (F^covariance = 9.982, P = 0.002) between the two groups. There was no significant difference in the incidence of adverse drug reactions (P > 0.05) between the two groups.

Conclusion

Metformin is able to improve amisulpride-induced hyperprolactinemia with its safety.

Association of Beta-Thalassaemia and Hypogonadotropic Hypogonadism

Thalassaemic syndromes are among the most common haemoglobinopathies and are associated with high morbidity and mortality. Because of the various treatments, a secondary endocrinopathy due to iron overload—haemosiderosis—can occur, causing hypopituitarism leading to hypogonadotropic hypogonadism (HH) and infertility. We present a case of secondary amenorrhoea in a patient with beta-thalassaemia and a history of multiple therapies in her adolescence, such as multiple transfusions, chemotherapy, and allogeneic bone marrow transplantation, who presented with HH and premature ovarian insufficiency.

Proton pump inhibitors therapy and risk of hyperprolactinemia with associated sexual disorders

Proton pump inhibitors (PPIs) are the most widely prescribed medications in the world. According to numerous studies, PPIs have been linked to hyperprolactinemia, which can lead to a variety of sexual and reproductive issues. This review summarizes the effects of numerous PPIs on the blood prolactin levels and associated sexual dysfunctions, which have an effect on the patient's life quality and fertility. The study is taken into account all the available resources till January 31, 2021. Out of total 364, only 27 relevant resources were involved in this review. In certain studies, short-term PPIs use has been shown to have little or no effect on the blood prolactin and other reproductive hormones levels. PPIs have been linked to the development of hyperprolactinemia in several case studies with varying degrees of the blood prolactin levels increase seen in individuals taking PPI alone or in combination with medications, like prokinetics. The relative risk of the sexual consequences development, such as gynecomastia, has been documented using lansoprazole and omeprazole in various cohort studies. On the other hand, other bits of data are insufficient to establish a definite relationship that can turn a possibility into certainty. The majority of the literature data is comprising of double-blind, randomized, crossover studies, case reports, and adverse drug reaction incidents reported to various pharmacovigilance centers. To investigate this link, high-quality studies in patients taking PPIs for a longer time period are needed. We conclude this article with a comprehensive discussion of the hyperprolactinemia clinical implications and the PPIs' function.

Classification of 27 Corynebacterium kroppenstedtii-Like Isolates Associated with Mastitis in China and Descriptions of C. parakroppenstedtii sp. nov. and C. pseudokroppenstedtii sp. nov

Corynebacterium, particularly Corynebacterium kroppenstedtii, has been increasingly recognized as an important pathogen causing mastitis. However, no clear taxonomic, microbiological, or clinical identification for C. kroppenstedtii-related Corynebacterium species is recognized. During the investigation of isolates cultured from female patients with mastitis, 27 lipophilic C. kroppenstedtii-like isolates were obtained from clinical breast specimens from 2017 to 2019 in Guangzhou, China. These isolates were identified by phenotypic characterization, matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), partial sequencing of the 16S rRNA, rpoB, and fusA genes, and whole-genome sequencing methods. By phylogenetic analyses, two major clusters were identified that were closely related to C. kroppenstedtii DSM 44385T. Comparative genome analyses suggested that these isolates formed two distinct genospecies within the genus Corynebacterium. The digital DNA-DNA hybridization (dDDH) values for the two genospecies were 45.5 to 47.8% between them and 47.4 to 47.7% and 49.9% to C. kroppenstedtii DSM 44385T, respectively. Based on these results, it can be concluded that these isolates need to be recognized as two new species of the genus Corynebacterium, for which we proposed the names Corynebacterium parakroppenstedtii sp. nov. and Corynebacterium pseudokroppenstedtii sp. nov. The type strain for the novel species Corynebacterium parakroppenstedtii is MC-26T (NBRC 115146T; CCTCC AB 2020210T), and that for Corynebacterium pseudokroppenstedtii is MC-17XT (NBRC 115143T; CCTCC AB 2020199T). IMPORTANCE In this study, we characterized two novel species that were closely related to but hard to distinguish from C. kroppenstedtii by routine identification methods used in clinical laboratories. Since all 27 C. kroppenstedtii-like isolates were obtained from breast specimens of female patients with mastitis, they may be potential pathogens causing mastitis. We hope to perform further epidemiological investigation of these strains and explore their role in mastitis.

Thyroid Diseases and Breast Cancer

Epidemiological studies aimed at defining the association of thyroid diseases with extra-thyroidal malignancies (EM) have aroused considerable interest in the possibility of revealing common genetic and environmental factors underlying disease etiology and progression. Over the years, multiple lines of evidence indicated a significant relationship between thyroid carcinomas and other primary EM, especially breast cancer. For the latter, a prominent association was also found with benign thyroid diseases. In particular, a meta-analysis revealed an increased risk of breast cancer in patients with autoimmune thyroiditis, and our recent work demonstrated that the odds ratio (OR) for breast cancer was raised in both thyroid autoantibody-positive and -negative patients. However, the OR was significantly lower for thyroid autoantibody-positive patients compared to the negative ones. This is in agreement with findings showing that the development of thyroid autoimmunity in cancer patients receiving immunotherapy is associated with better outcome and supports clinical evidence that breast cancer patients with thyroid autoimmunity have longer disease-free interval and overall survival. These results seem to suggest that factors other than oncologic treatments may play a role in the initiation and progression of a second primary malignancy. The molecular links between thyroid autoimmunity and breast cancer remain, however, unidentified, and different hypotheses have been proposed. Here, we will review the epidemiological, clinical, and experimental data relating thyroid diseases and breast cancer, as well as the possible hormonal and molecular mechanisms underlying such associations.

Incidence of heart valve disease in women treated with the ergot-derived dopamine agonist bromocriptine

BACKGROUND

Ergot-derived dopamine agonists are thought to induce fibrotic changes in cardiac valve leaflets. We sought to determine the incidence of heart valve disease in women treated with bromocriptine compared with age and sex matched controls from the background population.

METHODS

In nationwide Danish registries we identified female patients treated with bromocriptine in the period 1995-2018. Patients were included at date of second redeemed prescription and were matched 1:5 with controls from the background population based on age, sex and year of inclusion by use of incidence density sampling. The outcomes were hospital admission for or outpatient diagnosis of heart valve disease, and death as competing risk. Incidence rates, cumulative incidence curves, and adjusted cox-proportional hazard models adjusted for cardiovascular risk factors were used to assess outcomes in bromocriptine users versus controls.

RESULTS

A total of 3035 female bromocriptine users and 15,175 matched controls were included. Median age at inclusion was 32 years (Q1-Q3, 28-37 years). Both bromocriptine users and controls had few comorbidities and low use of concomitant pharmacotherapy. Within 10 years of follow-up, 11 patients (0.34%, 95% CI 0.13-0.55%) and 44 controls (0.29%, 95% CI 0.20-0.37) met the primary endpoint of heart valve disease, p = 0.63. The adjusted cox regression analysis yielded a hazard ratio of 0.96 (95% confidence interval (CI) 0.55-1.69, p = 0.89).

CONCLUSIONS

Treatment initiation with ergot-derived dopamine agonist bromocriptine in younger women with few comorbidities, was associated with a low absolute long-term risk of heart valve disease, not significantly different from the risk in age and sex matched population controls. Thus, indicating a low clinical yield of pre-treatment echocardiographic screening in this patient population in accordance with current guidelines.

Giant plurihormonal pituitary adenoma in a child - case study

OBJECTIVES

To describe the case of a 12-year-old girl with a rare plurihormonal pituitary macroadenoma secreting prolactin (PRL), growth hormone (GH), thyroid-stimulating hormone (TSH), and alpha subunit (α-SU).

CASE PRESENTATION

The patient experienced recurrent headaches and progressing loss of vision in one eye. During the examination, abnormalities such as tall stature, coarse facial features, enlarged feet and hands, tachycardia, hand tremor, hyperhidrosis, galactorrhea, and goiter were observed. Head magnetic resonance imaging (MRI) revealed a solid tumor in the anterior and middle cranial fossa, measuring 80 × 50 × 55 mm. A stereotactic biopsy revealed plurihormonal Pit-1 positive pituitary adenoma secreting PRL, GH, and TSH. A pituitary hyperfunction with PRL, GH, TSH, and α-SU excess was diagnosed. The patient was successfully treated pharmacologically with dopamine agonists and somatostatin analogue, and a decrease of tumor volume (30%) was achieved.

CONCLUSIONS

When neurosurgery is not possible, long-term pharmacological treatment of plurihormonal pituitary macroadenoma can be a safe and relatively effective alternative.

Efficacy and Cerebrospinal Fluid Rhinorrhea after Cabergoline Treatment in Patients with Bioactive Macroprolactinoma

Predicting dopamine agonist resistance in patients with macroprolactinoma is essential for clinicians to prevent treatment failure and subsequent complications such as medication-induced cerebrospinal fluid (CSF) rhinorrhea. We evaluated the features of patients with cabergoline resistance and CSF rhinorrhea in patients with prolactinomas with prolactin levels ≥1000 ng/mL. A total of 140 patients who were newly diagnosed with prolactinoma secreting only prolactin ≥1000 ng/mL and treated with cabergoline for the first time were included in this study. Based on the hormonal and radiologic response of the prolactinoma, the patients were divided into responders and non-responders. Non-responders (36/140, 25.8%) included a higher number of patients receiving hormone replacement than responders (responders, n (%) = 12(11.5) vs. non-responders = 13(36.1), p = 0.001). In propensity score matching analysis, patients who developed CSF rhinorrhea presented more frequent hormone deficiency than responders regardless of initial cabergoline dose. Hormone deficiency was associated with a greater odds ratio for the risk of non-responders (adjusted odds ratio = 5.13, 95% CI 1.96-13.46, p = 0.001). Cabergoline was effective in bioactive macroprolactinoma. Furthermore, initial cabergoline dose was not significantly associated with long-term responsiveness and development of CSF rhinorrhea but the hypopituitarism was independently associated with an increased risk of cabergoline resistance and CSF rhinorrhea.

Insights into the expanding phenotypic spectrum of inherited disorders of biogenic amines

Inherited disorders of neurotransmitter metabolism are rare neurodevelopmental diseases presenting with movement disorders and global developmental delay. This study presents the results of the first standardized deep phenotyping approach and describes the clinical and biochemical presentation at disease onset as well as diagnostic approaches of 275 patients from the registry of the International Working Group on Neurotransmitter related Disorders. The results reveal an increased rate of prematurity, a high risk for being small for gestational age and for congenital microcephaly in some disorders. Age at diagnosis and the diagnostic delay are influenced by the diagnostic methods applied and by disease-specific symptoms. The timepoint of investigation was also a significant factor: delay to diagnosis has decreased in recent years, possibly due to novel diagnostic approaches or raised awareness. Although each disorder has a specific biochemical pattern, we observed confounding exceptions to the rule. The data provide comprehensive insights into the phenotypic spectrum of neurotransmitter disorders.

Inherited disorders of neurotransmitter metabolism represent a group of rare neurometabolic diseases characterized by movement disorders and developmental delay. Here, the authors report a standardized evaluation of a registry of 275 patients from 42 countries, and highlight an evolving phenotypic spectrum of this disease group and factors influencing diagnostic processes.

Reproductive one health in primates

One Health is a collaborative trans-disciplinary approach to health; integrating human, animal, and environmental health. The focus is often on infection disease transmission and disease risk mitigation. However, One Health also includes the multidisciplinary and comparative approach to disease investigation and health of humans, animals, and the environment. One key aspect of environmental/ecosystem health is conservation, the maintenance of healthy, actively reproducing wildlife populations. Reproduction and reproductive health are an integral part of the One Health approach: the comparative aspects of reproduction can inform conservation policies or breeding strategies (in situ and ex situ) in addition to physiology and disease. Differences in reproductive strategies affect the impact poaching and habitat disruption might have on a given population, as well as ex situ breeding programs and the management of zoo and sanctuary populations. Much is known about chimpanzees, macaques, and marmosets as these are common animal models, but there is much that remains unknown regarding reproduction in many other primates. Examining the similarities and differences between and within taxonomic groups allows reasonable extrapolation for decision-making when there are knowledge gaps. For example: (1) knowing that a species has very low reproductive rates adds urgency to conservation policy for that region or species; (2) identifying species with short or absent lactation anestrus allows ex situ institutions to better plan contraception options for specific individuals or prepare for the immediate next pregnancy; (3) recognizing that progestin contraceptives are effective contraceptives, but may be associated with endometrial hyperplasia in some species (in Lemuridae but not great apes) better guides empirical contraceptive choice; (4) recognizing the variable endometriosis prevalence across taxa improves preventive medicine programs. A summary of anatomical variation, endocrinology, contraception, pathology, and diagnostics is provided to illustrate these features and aid in routine physical and postmortem examinations as well as primate management.

Pituitary apoplexy of a giant prolactinoma during pregnancy

AIMS AND METHODS

Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy.

RESULTS

A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life.

CONCLUSION

This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Bu-Shen-Zhu-Yun decoction induces PRLR deubiquitination and JAK2/STAT5 activation via CSN5 in vitro

Purpose: To determine the effect of Bu-Shen-Zhu-Yun Decoction (BSZY-D) on the kisspeptin through JAK2/STAT5 signaling pathway in hyperprolactinemia (HPRL) infertility.

Method: SD rats were treated with BSZY-D for cerebrospinal fluid (CSF) extraction. GT1-7 cells were subjected to different treatments. The phosphorylation levels of JAK2 and STAT5, and the expressions of PRLR and kisspeptin of GT1-7 cells in different groups were detected by western blot, RT-qPCR and immunofluorescence. The expressions of CSN5 and GATA1 and other molecular features were checked by western blot, RT-PCR, co-immunoprecipitation and renilla luciferase activity.

Results: The phosphorylation levels of JAK2 and STAT5, and the expressions of PRLR and kisspeptin in the HPRL group were significantly decreased, and these changes could be reversed after BSZY-D treatment. In addition, the presence of PRLR deubiquitination was detected in the HPRL group, which could be reversed by shRNA-CSN5, suggesting that BSZY-D played a role through targeting CSN5. The binding level of GATA1 and CSN5 promoter in the HPRL group was significantly decreased, but elevated in the HPRL (BSZY-D/CSF) group (P < 0.05).

Conclusion: BSZY-D improved the transcription activity of GATA1 and increased the binding of GATA1 and CSN5. BSZY-D was involved in the deubiquitination of PRLR, which contributes to alleviating the symptoms of HPRL infertility.

Utility of Cannulated Prolactin to Exclude Stress Hyperprolactinemia in Patients with Persistent Mild Hyperprolactinemia

Background

Stress-induced hyperprolactinemia can be difficult to differentiate from true hyperprolactinema and may result in patients having unnecessary investigations and imaging. We report the results of cannulated prolactin tests with serial prolactin measurements from an indwelling catheter to differentiate true from stress-induced hyperprolactinemia in patients with persistently mildly elevated prolactin levels in both referral and repeat samples.

Methods

Data were collected for 42 patients who had a cannulated prolactin test between January 2017 and May 2018. After cannula insertion, prolactin was measured at 0, 60, and 120 minutes. Normalization is defined as a decline in prolactin to gender-defined normal ranges.

Results

The mean age was 33.8 years (SD ± 9.9), and 37 (88%) were female. Menstrual irregularities were the main presenting symptom in 28.57% of the patients. Prolactin normalized in 12 (28.6%) patients of whom cannulated prolactin test was done. Repeat random prolactin levels were significantly higher in patients whose prolactin did not normalize during the cannulated prolactin test. MRI of the pituitary gland showed an abnormality in 23 out of 28 (82%) patients who did not normalize prolactin, a microadenoma in the majority of patients (18 patients).

Conclusion

The cannulated prolactin test was useful in excluding true hyperprolactinemia in 28.6% of patients with previously confirmed mildly elevated random prolactin on two occasions, thus avoiding over-diagnosis and unnecessary imaging.

Vitamin D status determines the impact of metformin on circulating prolactin levels in premenopausal women

WHAT IS KNOWN AND OBJECTIVE

Metformin was found to normalize secretory function of overactive pituitary cells. Its effect on circulating thyrotropin levels was more pronounced in women receiving exogenous vitamin D. The aim of the current study was to investigate whether vitamin D status determines the impact of metformin on prolactin levels in premenopausal women with hyperprolactinaemia.

METHODS

The study population consisted of three groups of women with prediabetes and elevated prolactin levels: vitamin D-naïve women with vitamin D insufficiency (group 1; n = 19), women receiving vitamin D preparations because of vitamin D deficiency (group 2 n = 20), as well as vitamin D-naïve women with normal vitamin D status (group 3 n = 23). All participants were then treated with metformin (2.55-3 g daily). Circulating levels of glucose, insulin, prolactin, thyrotropin, free thyroid hormones, gonadotropins, estradiol, calcium and 25-hydroxyvitamin were determined at baseline and six months later.

RESULTS AND DISCUSSION

At baseline, prolactin levels were higher in group 1 than in the remaining groups of patients. Although metformin decreased glucose levels and improved insulin sensitivity in all treatment groups, this effect was more pronounced in groups 2 and 3. Only in subjects with 25-hydroxyvitamin D levels within the reference range, metformin reduced prolactin levels. The impact on prolactin levels correlated with 25-hydroxyvitamin D levels and with the improvement in insulin sensitivity. The drug produced a neutral effect on circulating levels of thyrotropin, free thyroid hormones, gonadotropins, estradiol, calcium and 25-hydroxyvitamin D.

WHAT IS NEW AND THE CONCLUSION

The results of the current study suggest that the impact of metformin on secretory function of overactive lactotropes depends on the vitamin D status of patients.

Psychological aspects of infertility. A systematic review

Objective

Fertility may be defined as a capacity to conceive and produce offspring. Infertility is characterized by failure to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse. Infertility concerns an estimated 8–12% of the global population, and is associated with factors including time of unwanted non-conception, age of female partner and number of diseases impacting fertility. Unexplained infertility is described as idiopathic. This study aimed to analyse and evaluate the influence of mental disorders, often considered as reasons for idiopathic infertility, on female and male fertility, including stress, depression, sleep and eating disorders, and addictions.

Methods

This systematic review comprised a search of MEDLINE, Cochrane and PubMed databases for relevant articles that were analysed by two independent reviewers.

Results

A total of 106 articles published between 1955–2019 were included. Mental disorders modify endocrine gland and immune system functioning at both the tissue and cellular level, and are negatively associated with female and male fertility.

Conclusion

Mental disorders may negatively impact female and male fertility. Further studies are required to explain the exact role and contribution of mental disorders to fertility.

Pituitary Adenomas: From Diagnosis to Therapeutics

Pituitary adenomas are tumors that arise in the anterior pituitary gland. They are the third most common cause of central nervous system (CNS) tumors among adults. Most adenomas are benign and exert their effect via excess hormone secretion or mass effect. Clinical presentation of pituitary adenoma varies based on their size and hormone secreted. Here, we review some of the most common types of pituitary adenomas, their clinical presentation, and current diagnostic and therapeutic strategies.

A retrospective study of pituitary-thyroid interaction in patients with first-episode of bipolar disorder type I in Mania State

ABSTRACT

Bipolar disorder (BD)-mania is related to the dysfunction of anterior pituitary gland, but the pituitary-thyroid interaction on the acute stage of BD has been controversial. In order to rule out the effects of drugs, we aimed to determine the upstream interaction of first-episode of BD type I in mania state, and tried to find the relationship between thyroid-stimulating-hormone (TSH) and Prolactin (PRL)This study included 70 real-world patients diagnosed with first-episode BD-mania recuited and 70 healthy controls (HC) matched for age and sex from 2016 to 2017 in the same district of Shanghai. We compared the levels of thyroid hormones and prolactin between the two groups, and linear regression and curve estimation were used for the correlation analysis of TSH and PRLThere were differences in triiodothyronine (TT3), total thyroxin (TT4), and free thyroxine (FT4) concentrations between the groups (P's < .05). After being grouped by sex, higher PRL in the male and female BD-mania subgroup were observed compared to each isosexual HC [(P's < .01, Cohen's d = 0.82/1.08, 95%CI (0.33, 1.31)/(0.58, 1.58)]. Higher FT4 in the male BD-mania group was observed compared to the HC males [(P's  < .01, Cohen's d = 0.90, 95%CI (0.41, 1.39)] while the female BD-mania group showed lower TT3 and TT4 compared to the HC females [(P's  < .01, Cohen's d = 0.93/0.88, 95%CI (0.43, 1.42)/(0.39, 1.37)]. In the female BD-mania group, correlation analysis established an inverse relationship between PRL and TSH (r2 = 0.25, F = 11.11, P < .01).The findings demonstrate that sex impacts the concentration of hormones secreted by the anterior pituitary of patients with first-episode BD-mania. The increased PRL may be a putative mechanism that underlies the onset in female patients with a moderate inverse relationship between TSH and PRL. Thyroid hormones and prolactin levels may be developed as potential markers for identifying BD-manic.

Introduction of Female Reproductive Processes and Reproductive Diseases

The female reproductive process is very complicated, including multiple processes. Each process is different and plays a vital role in reproduction. If some reproductive diseases occur, these processes will be abnormal, causing infertility problem. In this Chapter, we will describe the female reproductive process and their corresponding reproductive diseases.

Patterns of prolactin secretion

Prolactin is pleotropic in nature affecting multiple tissues throughout the body. As a consequence of the broad range of functions, regulation of anterior pituitary prolactin secretion is complex and atypical as compared to other pituitary hormones. Many studies have provided insight into the complex hypothalamic-pituitary networks controlling prolactin secretion patterns in different species using a range of techniques. Here, we review prolactin secretion in both males and females; and consider the different patterns of prolactin secretion across the reproductive cycle in representative female mammals with short versus long luteal phases and in seasonal breeders. Additionally, we highlight changes in the pattern of secretion during pregnancy and lactation, and discuss the wide range of adaptive functions that prolactin may have in these important physiological states.

HYPERPROLACTINEMIA IN A TRANSGENDER MALE

OBJECTIVE

We present a case of hyperprolactinemia in a transgender male. We discuss the various etiologies for hyperprolactinemia in this population of patients and discuss management options.

METHODS

We present a case report and review of the literature. A 29-year-old transgender male treated with gender-affirming hormone therapy with testosterone presented with hyperprolactinemia.

RESULTS

Labs revealed an elevated prolactin level. The patient completed further laboratory evaluation as well as imaging with a pituitary magnetic resonance imaging which all revealed normal results. He was wearing a tightly fitted breast binder while awaiting bilateral mastectomy. After bilateral mastectomy prolactin normalized, suggesting breast binding as the cause of the elevated prolactin.

CONCLUSION

This is the only case in the literature which highlights breast binding as a possible cause of an elevated prolactin level. Our case report illustrates the various etiologies associated with an elevated prolactin level and highlights the importance of considering unique etiologies in populations such as transgender males.

Hyperprolactinaemia

Hyperprolactinaemia is one of the most common problems in clinical endocrinology. It relates with various aetiologies (physiological, pharmacological, pathological), the clarification of which requires careful history taking and clinical assessment. Analytical issues (presence of macroprolactin or of the hook effect) need to be taken into account when interpreting the prolactin values. Medications and sellar/parasellar masses (prolactin secreting or acting through “stalk effect”) are the most common causes of pathological hyperprolactinaemia. Hypogonadism and galactorrhoea are well-recognized manifestations of prolactin excess, although its implications on bone health, metabolism and immune system are also expanding. Treatment mainly aims at restoration and maintenance of normal gonadal function/fertility, and prevention of osteoporosis; further specific management strategies depend on the underlying cause. In this review, we provide an update on the diagnostic and management approaches for the patient with hyperprolactinaemia and on the current data looking at the impact of high prolactin on metabolism, cardiovascular and immune systems.

Bone loss caused by dopaminergic degeneration and levodopa treatment in Parkinson's disease model mice

Accumulating evidence have shown the association of Parkinson’s disease (PD) with osteoporosis. Bone loss in PD patients, considered to be multifactorial and a result of motor disfunction, is a hallmark symptom that causes immobility and decreased muscle strength, as well as malnutrition and medication. However, no known experimental evidence has been presented showing deleterious effects of anti-PD drugs on bone or involvement of dopaminergic degeneration in bone metabolism. Here, we show that osteoporosis associated with PD is caused by dopaminergic degeneration itself, with no deficit of motor activity, as well as treatment with levodopa, the current gold-standard medication for affected patients. Our findings show that neurotoxin-induced dopaminergic degeneration resulted in bone loss due to accelerated osteoclastogenesis and suppressed bone formation, which was associated with elevated prolactin. On the other hand, using an experimental model of postmenopausal osteoporosis, dopaminergic degeneration did not result in exacerbation of bone loss due to estrogen deficiency, but rather reduction of bone loss. Thus, this study provides evidence for the regulation of bone metabolism by the dopaminergic system through both gonadal steroid hormone-dependent and -independent functions, leading to possible early detection of osteoporosis development in individuals with PD.

Analysis of Catecholamines and Pterins in Inborn Errors of Monoamine Neurotransmitter Metabolism-From Past to Future

Inborn errors of monoamine neurotransmitter biosynthesis and degradation belong to the rare inborn errors of metabolism. They are caused by monogenic variants in the genes encoding the proteins involved in (1) neurotransmitter biosynthesis (like tyrosine hydroxylase (TH) and aromatic amino acid decarboxylase (AADC)), (2) in tetrahydrobiopterin (BH₄) cofactor biosynthesis (GTP cyclohydrolase 1 (GTPCH), 6-pyruvoyl-tetrahydropterin synthase (PTPS), sepiapterin reductase (SPR)) and recycling (pterin-4a-carbinolamine dehydratase (PCD), dihydropteridine reductase (DHPR)), or (3) in co-chaperones (DNAJC12). Clinically, they present early during childhood with a lack of monoamine neurotransmitters, especially dopamine and its products norepinephrine and epinephrine. Classical symptoms include autonomous dysregulations, hypotonia, movement disorders, and developmental delay. Therapy is predominantly based on supplementation of missing cofactors or neurotransmitter precursors. However, diagnosis is difficult and is predominantly based on quantitative detection of neurotransmitters, cofactors, and precursors in cerebrospinal fluid (CSF), urine, and blood. This review aims at summarizing the diverse analytical tools routinely used for diagnosis to determine quantitatively the amounts of neurotransmitters and cofactors in the different types of samples used to identify patients suffering from these rare diseases.