Color Doppler analysis of uterine, spiral, and intraovarian artery blood flow before and after treatment with cabergoline in hyperprolactinemic patients

Prolactin (PRL) may have stimulatory effects on vascular resistance. We aimed to analyze uterine, spiral, and intraovarian artery blood flow by Doppler ultrasonography in hyperprolactinemic patients prior to and after treatment with cabergoline. The study was conducted in Sisli Etfal Training and Research Hospital gynecology outpatient clinic between 1 March 2010 and 30 September 2011. Twenty-four women with symptomatic hyperprolactinemia in reproduction age were included in the study. All hyperprolactinemic patients were studied prior to and following the suppression of circulating PRL levels by cabergoline. Patients were examined by standard B-mod and color transvaginal ultrasonography. Pulsality index (PI), resistance index (RI), and systolic/diastolic ratio (S/D) were recorded. The median PRL value was 86 (62-120) ng/ml before treatment and 4.0 (2.5-6.4) ng/ml after the treatment (p < 0.001). We found a significant association among PRL, uterine, spiral, and intraovarian artery RI with linear regression analysis (p < 0.001 for all three arteries). Uterine, spiral, and intraovarian artery PI (p = 0.021, p < 0.001, and p < 0.001, respectively) and RI (p = 0.001, p < 0.001, and p < 0.001, respectively) significantly decreased after cabergoline treatment. In conclusion, this is a pilot study which shows for the first time that PRL increases the uterine, endometrial, and intraovarian vascular resistance and cabergoline reverses this effect.

[Dopamin agonist treatment and fibrotic heart valve disease in hyperprolactinaemia patients]

Treatment with dopamin agonists, particularly cabergoline, is the primary and preferred therapy for prolactinomas and symptomatic hyperprolactinaemia due to its effectiveness and tolerability. However, an association has been demonstrated between fibrotic heart valve disease and high-dose dopamin agonist use in patients with Parkinson's disease in several echocardiographic studies. Such observations have prompted a number of studies of valvular function in cabergoline-treated hyperprolactinaemia patients. These studies have failed to show an increased prevalence of clinically significant valvular regurgitation.

A cross-sectional study of the prevalence of cardiac valvular abnormalities in hyperprolactinemic patients treated with ergot-derived dopamine agonists

CONTEXT

Concern exists in the literature that the long-term use of ergot-derived dopamine agonist drugs for the treatment of hyperprolactinemia may be associated with clinically significant valvular heart disease.

OBJECTIVE

The aim of the study was to determine the prevalence of valvular heart abnormalities in patients taking dopamine agonists as treatment for lactotrope pituitary tumors and to explore any associations with the cumulative dose of drug used.

DESIGN

A cross-sectional echocardiographic study was performed in a large group of patients who were receiving dopamine agonist therapy for hyperprolactinemia. Studies were performed in accordance with the British Society of Echocardiography minimum dataset for a standard adult transthoracic echocardiogram. Poisson regression was used to calculate relative risks according to quartiles of dopamine agonist cumulative dose using the lowest cumulative dose quartile as the reference group.

SETTING

Twenty-eight centers of secondary/tertiary endocrine care across the United Kingdom participated in the study.

RESULTS

Data from 747 patients (251 males; median age, 42 y; interquartile range [IQR], 34-52 y) were collected. A total of 601 patients had taken cabergoline alone; 36 had been treated with bromocriptine alone; and 110 had received both drugs at some stage. The median cumulative dose for cabergoline was 152 mg (IQR, 50-348 mg), and for bromocriptine it was 7815 mg (IQR, 1764-20 477 mg). A total of 28 cases of moderate valvular stenosis or regurgitation were observed in 24 (3.2%) patients. No associations were observed between cumulative doses of dopamine agonist used and the age-corrected prevalence of any valvular abnormality.

CONCLUSION

This large UK cross-sectional study does not support a clinically concerning association between the use of dopamine agonists for the treatment of hyperprolactinemia and cardiac valvulopathy.

Approach to the patient with persistent hyperprolactinemia and negative sellar imaging

Hyperprolactinemia is a common cause of menstrual disturbances affecting young women. There is a diversity of causes, from physiological, such as pregnancy, to pharmacological and pathological, such as hypothyroidism. Renal and hepatic failure, intercostal nerve stimulation by trauma or surgery, prolactinomas, other tumors in the hypothalamus-pituitary region, as well as macroprolactinemia can also be considered. Identifying the correct cause is important to establish the correct treatment. Should all these causes be ruled out and pituitary imaging revealed as negative, idiopathic hyperprolactinemia is therefore diagnosed. In symptomatic patients, treatment with dopaminergic agonists is indicated. As for the asymptomatic hyperprolactinemic individuals, macroprolactinemia should be screened, and once it is detected, there is no need for pituitary imaging study or for dopaminergic agonist use.

Suprasellar tuberculoma presenting as panhypopituitarism

Suprasellar tuberculomas are exceptionally rare. We present the case of a middle aged male who presented with generalised apathy and meningism of two weeks duration. Neuroimaging was suggestive of tuberculomas in suprasellar cistern, while endocrinological investigation showed panhypopituitarism manifesting as pituitary hypothyroidism, hypocortisolism, and hyperprolactinemia. Cerebrospinal fluid examination showed lymphocytic reaction with raised proteins. A diagnosis of suprasellar tuberculoma with panhypopituitarism was made. The patient was started on antituberculous treatment and hormone replacement which led to remarkable improvement in condition of patient and resolution of tuberculous granuloma in follow up imaging.

Gender effects on cardiac valvular function in hyperprolactinaemic patients receiving cabergoline: a retrospective study

BACKGROUND

Ergot-derived dopamine agonists are associated with increased risk of valvular dysfunction in Parkinson's disease. The risk of valvular disease associated with lower doses of cabergoline used to treat prolactinomas remains controversial.

OBJECTIVE

To determine whether there is an association of cabergoline and valvular function in patients with hyperprolactinaemia according to gender.

DESIGN

Case-record retrospective study.

SETTING

Outpatient neuroendocrine clinical centre at a tertiary care hospital.

STUDY PARTICIPANTS

One hundred patients (48 men and 52 women) with hyperprolactinaemia who had an echocardiogram while receiving cabergoline for at least 6 months.

CONTROLS

One hundred controls (48 men and 52 women) selected from Massachusetts general hospital (MGH) database of echocardiograms without clinically significant findings, matched to patients for age, gender, body mass index (BMI) and hypertension.

MAIN OUTCOME MEASURE

Echocardiogram.

RESULTS

There were no significant differences in valvular function in patients compared with controls. However, women patients had a higher prevalence of mild tricuspid regurgitation (TR) than female controls (15.4%vs. 1.9%, P = 0.03). Among men only, patients had more trace TR than controls (68.8%vs. 45.8%, P = 0.02). The mild valvular regurgitation in patients was not clinically significant and did not correlate with dose, duration or cumulative dose.

CONCLUSIONS

Overall cabergoline was not associated with valvulopathy. However, subdivided by gender, hyperprolactinaemic men and women had higher prevalence of trace or mild TR, respectively, compared with gender matched controls. There may be gender differences in valvular dysfunction associated with cabergoline. Longer term, larger studies are necessary to evaluate definitively an effect of cabergoline on valvular function in hyperprolactinaemic patients.

Patients with macroprolactinaemia: clinical and radiological features

BACKGROUND

Macroprolactinaemia may represent a relevant cause of misdiagnosis, unnecessary investigation and inappropriate treatment. The aim of this study was to investigate the clinical and neuroradiological characteristics of patients with and without macroprolactinaemia and to evaluate the impact of macroprolactin determination on the diagnostic work-up of hyperprolactinaemic patients.

MATERIALS AND METHODS

Retrospective analysis in 135 consecutive hyperprolactinaemic patients (111 women and 24 men; mean age 37 +/- 11.6 years) whose archived sera were subsequently tested for macroprolactin. Recoveries </= 40% after polyethylene glycol precipitation were indicative of macroprolactinaemia.

RESULTS

Macroprolactin, entirely explaining biochemical hyperprolactinaemia, was found in 42.2% of patients, a third of whom presented with signs and symptoms of hyperprolactinaemia. Determination of macroprolactin changed the initial diagnosis in a consistent proportion of patients. In particular, idiopathic hyperprolactinaemia, initially diagnosed in 41 patients, was then excluded in 28 of them. Diagnosis of prolactin-secreting pituitary microadenoma shifted to non-secreting pituitary microadenoma in 10 of 49 patients, while in all patients with prolactin-secreting pituitary macroadenoma or hyperprolactinaemia due to stalk deafferentation the presence of macroprolactin was excluded and the initial diagnosis confirmed. Finally, macroprolactin was present in the majority of patients with magnetic resonance imaging (MRI) scans suggestive for primary empty sella (4 of 5 women) or pituitary hyperplasia (12 of 17 women, 3 of 3 men). Collectively, about half of subjects with macroprolactinaemia showed variable MRI abnormalities.

CONCLUSIONS

The presence of macroprolactin was a relevant cause of misdiagnosis in patients with hyperprolactinaemia. However, due to the unexpected high frequency of pituitary abnormalities observed in the present series, we suggest that the diagnostic algorithm of hyperprolactinaemic states should include both polyethylene glycol precipitation test and MRI imaging.

Drug treatment of hyperprolactinemia

Medical treatment of hyperprolactinemia is based upon use of dopamine agonists (DA): bromocriptine, lisuride, quinagolide and cabergoline. In over 80% of cases, these drugs induce normal prolactinemia and ovulatory cycles. In resistant cases, the DA should be changed. Tolerance may occasionally be poor, particularly with bromocriptine, which appears less well-tolerated than quinagolide and than cabergoline above all. In the event of intolerance to a given DA, another should be tried. In patients with macroprolactinoma treated with DA, MRI monitoring should be carried out after 3 months of treatment to verify tumor size reduction, then after 1 year, yearly for the next 5 years and once every 5 years if adenoma size is stable. In cases of microprolactinoma, control under treatment is pointless. MRI may be performed after 1 year and then after 5 years. Once normal prolactin levels have been achieved, attempts may be made to stop the treatment. When a prolonged treatment is interrupted, especially with cabergoline, progressive increase in serum prolactin and return of hyperprolactinemia symptoms are seen in only around 20-30% of cases, particularly when residual adenoma exists after prolonged treatment. Nevertheless, prolactin levels should continue to be monitored after discontinuation of DA, possibly with MRI monitoring, since prolactin levels may rise again after a number of months or years. When normal prolactin levels have been achieved with DA, another solution consists in reducing the dose or dosing frequency of DA in steps to the lowest effective dose consistent with maintenance of normal prolactin levels and stable adenoma size. For drug-induced hyperprolactinemia, where the causative medication cannot be withdrawn, it is often pointless and possibly even dangerous to administer a DA. It is therefore necessary to check for absence of pituitary adenoma and where necessary, begin treatment with sex steroids so as to ensure satisfactory impregnation with sex steroids and avoid osteoporosis. For macroprolactinoma, the first-line treatment is drug therapy with DA. At present, there is no evidence to suggest that prior treatment with DA can modify the outcome of surgery. With microprolactinoma, DA treatment offers a good first-line therapeutic option but surgery may also be useful. DAs for microprolactinoma may be withdrawn after menopause.

Clinical and radiological features of patients with macroprolactinaemia

OBJECTIVES

Macroprolactin is a complex of prolactin (PRL) and IgG and may account for a significant proportion of cases of 'idiopathic hyperprolactinaemia'. In this study, we sought to determine the prevalence and clinical features of macroprolactinaemia in patients diagnosed with hyperprolactinaemia in our region, with a view to determining how patients with macroprolactinaemia should be investigated and managed.

PATIENTS AND METHODS

An Immuno-1 automated immunoassay system with polyethylene glycol (PEG) precipitation was used to identify macroprolactin, with a recovery of </= 50% taken as indicating significant macroprolactinaemia. Macroprolactin was found in 58 (21%) of 273 patients with a total PRL > 700 mU/l. The clinical records of 51 (44 female) were available for retrospective review.

RESULTS

The mean (range) age of patients was 39.5 (18-82) years. The median (range) concentrations for the various forms of PRL were: total PRL 1130 mU/l (728-5116), monomeric PRL 240 mU/l (50-656) and macroprolactin 895 mU/l (381-4854). Classical symptoms of hyperprolactinaemia were present in 39% of patients, although in many there were other possible explanations for their symptomatology. Pituitary adenomas were identified in six out of 36 people who underwent neuroimaging. Five of these patients had a microadenoma and one had a 10-mm macroadenoma (although, in this patient macroprolactin was identified after the discovery of the tumour). There was no relationship between macroprolactin concentrations and the presence of hyperprolactinaemic symptoms or neuroimaging abnormalities.

CONCLUSIONS

Macroprolactinaemia is a common occurrence in patients with hyperprolactinaemia, but associated symptomatology may not necessarily be linked. The neuroimaging abnormalities were also probably incidental findings and it is questionable whether neuroimaging is necessary when significant macroprolactinaemia is identified and the concentration of monomeric PRL is not elevated (using the Immuno-1 assay system, following PEG precipitation).

Androgen suppression and clinical improvement with dopamine agonists in hyperandrogenic-hyperprolactinemic women

OBJECTIVE

To examine the effect of dopamine agonist (DA) treatment on clinical and biochemical features in hirsute, hyperprolactinemic (HPRL) women and the relationship between prolactin (PRL) and androgens.

STUDY DESIGN

We evaluated 80 hirsute HPRL women (age, 27 +/- 1 years [mean +/- SE]) with neuroleptic treatment, prolactinoma and idiopathic HPRL (12, 13 and 55, respectively). DA, mainly bromocriptine, was administered for 11 +/- 1 months. Response indicators were Ferriman-Gallwey hirsutism (FGS) and Leeds acne (LAS) scores, circulating PRL, dehydroepiandrosterone sulfate (DHEAS), free and total testosterone, and androstenedione.

RESULTS

Baseline PRL correlated positively with DHEAS (r = .23, P = .03) and free testosterone (r = .36, P < .001). In all women, FGS, LAS, PRL, free testosterone, DHEAS and androstenedione decreased by 40-85% during DA treatment (P < .001). The decline in free testosterone was higher when PRL was > or = 65 ng/mL than when PRL was < 65 (P = .03) and correlated positively with basal DHEAS (r = .40, P < .001).

CONCLUSION

Our data suggest a modulation by PRL of adrenal androgen production. DA treatment reduces PRL and serum androgens. It results in a significant clinical improvement in acne and hirsutism. Therefore, DA is recommended as monotherapy for hyperandrogenic.

[An increased prevalence of thyroid echographic and autoimmune changes in hyperprolactinemic women on therapy with dopaminergic drugs]

Prolactin (PRL) possesses mitogenic and immunomodulatory properties. We evaluated the prevalence of ultrasonographic thyroid alterations and thyroid autoimmunity in hyperprolactinaemic (HPRL) women and correlated these with PRL levels. Furthermore, we studied the PRL binding in human benign nodular thyroid tissues. 133 HPRL patients (16-63 years) and 103 healthy female controls (16-63 years) with no known history of thyroid disease were studied. Blood samples were collected for PRL, FT3, FT4, TSH, thyroid peroxidase auto-antibodies (TPO Ab) and thyroglobulin auto-antibodies (Tg Ab) assays. All subjects underwent thyroid ultrasonography. PRL binding to thyroid membranes was determined by in-vitro radioreceptor assay in 5 human benign nodular thyroid fragments obtained from female patients. No difference in TSH levels was found, while FT3 (4.5 +/- 0.1 pmol/L) and FT4 (16.2 +/- 0.4 pmol/L) levels were significantly higher in controls than in HPRL (FT3: 3.8 +/- 0.1 pmol/L, p = 0.01, FT4: 15.4 +/- 0.2 pmol/L, p = 0.04). The prevalence of thyroid ultrasonographic alterations (simple goitre, uni-multinodular goitre, chronic thyroiditis) was significantly higher in HPRL (30.8%) than in controls (15.5%, p = 0.01) but did not correlate with mean initial and actual PRL levels or duration of the disease. The prevalence of autoantibodies was significantly higher in HPRL (29.6%) than in controls (14.3%, p = 0.04) but did not correlate with PRL levels. Very low specific PRL binding to thyroid membranes was detected. The high prevalence of thyroid ultrasonographic alterations and autoimmunity in HPRL suggests a possible role of PRL in the development of thyroid diseases. Clinical and instrumental thyroid screening may therefore be advisable in these patients.

Psychological distress in patients with hyperprolactinaemia

OBJECTIVE

In addition to the physical symptoms of galactorrhoea and amenorrhoea, hyperprolactinaemia in women is also reported to be associated with psychological symptoms. Previous studies have found an increased incidence of depression, anxiety and hostility in female patients with hyperprolactinaemia. In this study, psychological symptoms were assessed in a large population of patients and symptom scores were compared between patients with definite evidence of pituitary adenoma on high-resolution CT scanning and those without, who were presumed to have idiopathic or 'functional' hyperprolactinaemia.

DESIGN

Postal survey: population-control study of female patients with hyperprolactinaemia.

PATIENTS

Sixty-five women with hyperprolactinaemia were compared with a control group of 26 women with normoprolactinaemic pituitary disease (acromegaly or nonfunctioning pituitary adenoma). The hyperprolactinaemic patients were subdivided according to whether a pituitary adenoma was visible on high-resolution CT scanning (39 patients) or whether they had normal CT scans, in which case they were categorized as having idiopathic or 'functional' hyperprolactinaemia (26 patients).

MEASUREMENTS

Patients were sent 2 questionnaires, the Hospital Anxiety and Depression (HAD) Scale and the 90-item Symptom Checklist (SCL-90), to assess psychological wellbeing.

RESULTS

Overall, 54% of hyperprolactinaemic patients were found to have definite or borderline anxiety as judged by HAD scores, compared with 27% of normoprolactinaemic control patients. Those with normal CT scans were significantly more likely to have definite or borderline anxiety (73% of patients) than those with CT evidence of a pituitary tumour causing their hyperprolactinaemia (41%, P < 0.003), despite similar levels of serum prolactin. A similar increased proportion of hyperprolactinaemic patients scored highly on the anxiety component of the SCL-90, although mean scores were not different from controls. No differences were seen in scores for depression, but both subgroups of hyperprolactinaemic patients scored more highly than controls for hostility on the SCL-90 questionnaire.

CONCLUSION

These findings confirm the presence of significant anxiety in a proportion of women with hyperprolactinaemia. Hyperprolactinaemic women with no abnormality on CT scans displayed more psychological distress than those with definite pituitary microadenomas. These results may provide insight into the pathogenesis of 'functional' hyperprolactinaemia.

Adrenocorticotropic hormone and beta-endorphin concentrations in the inferior petrosal sinuses in Cushing's disease and other pituitary diseases

Aim of the present study was the evaluation of ACTH and beta-endorphin-like-immunoreactivity (beta-ELI) in the inferior petrosal sinuses (IPS's) and in the peripheral blood of patients with Cushing's disease (Group 1), with GH- or PRL-secreting adenomas or nontumoral hyperprolactinemia (Group 2). These patients had undergone selective and bilateral simultaneous IPS sampling for diagnostic purposes or for neurosurgical indications. In the patients of Group 1, ACTH and beta-ELI levels were higher in the IPS ipsilateral than in the contralateral to the adenoma and in the periphery (p < 0.001). In the patients of Group 2 ACTH and beta-ELI levels were higher in the IPS's than in the peripheral blood (p < 0.001) and, in the 9 patients with GH- or PRL-secreting adenomas, they were higher in the IPS ipsilateral than in the contralateral to the adenoma and in the periphery (p < 0.05). A significant correlation exists between ACTH and beta-ELI in the periphery (p < 0.01; r = 0.72), in the IPS ipsilateral (p < 0.05; r = 0.54) and contralateral (p < 0.01; r = 0.66) to the adenoma in Group 1, but not in Group 2. In conclusion, higher beta-ELI levels were detected in the IPS's than in the peripheral blood not only in patients with Cushing's disease but also in those with other pituitary diseases not involving ACTH secretion. The absence of correlation between ACTH and beta-ELI in patients not bearing Cushing's disease suggests that in these conditions corticotrophs release ACTH and beta-endorphin in an independent manner.

A longitudinal analysis of premenopausal bone loss in healthy women and women with hyperprolactinemia

In this report we describe longitudinal measurements of forearm and spinal bone mineral in healthy women and women with hyperprolactinemia. One hundred and ten women underwent yearly assessment of forearm and spinal bone mineral by single photon absorptiometry and computed tomography for an average of 4.7 yr. At entry into the study, women with hyperprolactinemic amenorrhea had 21% lower spinal bone mineral and 2.5% lower forearm bone mineral than healthy premenopausal women. Despite decreased estradiol levels (31 +/- 23 pmol/L), spinal bone in women with hyperprolactinemic amenorrhea did not change over time (+0.08%/yr; P = 0.89). In contrast, spinal bone in healthy women with regular menses (mean age, 34.6 +/- 6.6 yr) decreased significantly (1.7%/yr; P = 0.01). Cortical bone in the forearm did not change in either group. The hyperprolactinemic subjects had higher body mass index (28 +/- 6 vs. 24 +/- 4 kg/m2) and serum testosterone (0.5 +/- 0.2 vs. 0.39 +/- 0.16 pmol/L) than control subjects, but neither parameter correlated with bone loss. Although 64% of the hyperprolactinemic subjects had serum estradiol levels below 30 pmol/L, there was no correlation between estradiol or duration of amenorrhea and bone loss. Women with normal PRL levels and regular menses 3-9 yr after treatment of hyperprolactinemia had significantly lower spinal bone mineral (147 +/- 28 mg/mL) than healthy premenopausal women (169 +/- 29 mg/mL) and showed no change in spinal bone (+0.3%/yr; P = 0.67) over 5 yr. Despite significant hypoestrogenemia, women with hyperprolactinemic amenorrhea did not evidence a rapid decline in spinal bone. Restoration of gonadal function was not associated with normalization of bone mineral. The bone loss that accompanies hyperprolactinemia is not comparable to that which occurs after oophorectomy or menopause. These findings raise important questions about the importance of osteopenia as an indication for treatment of hyperprolactinemic amenorrhea.

Oral and injectable long-lasting bromocriptine preparations in hyperprolactinemia: comparison of their prolactin lowering activity, tolerability and safety

Bromocriptine, a D2 receptor agonist, has been widely used in tumoral and non-tumoral hyperprolactinemia, in reducing both plasma prolactin levels and in restoring fertility and/or menses in most patients. In this study a comparison between the injectable repeatable and the oral slow release formulations of bromocriptine (Parlodel LAR and Parlodel SRO) is reported, with respect to their effectiveness, tolerability and safety. Eleven patients with hyperprolactinemia, submitted to both treatments, were studied for a period of 1-24 months. Among the four patients with macroprolactinoma, three reached normoprolactinemia without complaining of side-effects, with both formulations, while the remaining patient became intolerant of the oral form after 1 year, and is presently being treated with the injectable formulation without presenting any side-effects. Among the five patients with microprolactinoma, two patients had a good response to both drugs; two patients did not reach normoprolactinemia with the injectable formulations, but a progressive decrease of prolactin levels was obtained with Parlodel SRO therapy, and the remaining patient was completely intolerant of the oral form without complaining of side-effects with Parlodel LAR. Two patients had non-tumoral hyperprolactinemia: one was intolerant of both drugs and one tolerated both formulations very well. In conclusion, Parlodel LAR and Parlodel SRO are very effective compounds in the medical treatment of hyperprolactinemic syndromes. The availability of these differing formulations improves the medical therapy, allowing a better choice of therapeutic regimen according to the effectiveness of, and tolerability to, the different drug formulations. In this way also, with poorly tolerant patients, it is possible to choose the better tolerated and more effective formulation of the drug.

Computed tomography of the brain in patients with serum prolactin levels over 200 ng/ml

We reviewed the computed tomographic (CT) findings of the sella turcica in 26 patients with a serum prolactin level of over 200 ng/ml. The interval between the dates of CT examination and checking of the serum prolactin level were within 2 months. There were 24 nonpregnant women with a mean age of 30 years and 2 men with a mean age of 28.5 years. None of them were taking medication known to cause an elevation in serum prolactin levels. Surgery was performed on 8 patients with chromophobe adenomas of the pituitary gland: 6 of them were proven to have prolactin-secreting tumors (prolactinomas) after performing a special stain, and the remaining 2 patients, clinically diagnosed as prolactinomas, showed extremely high serum prolactin levels (3,200 and 2,251 ng/ml, respectively). CT studies showed that the height of the pituitary gland in the coronal sections were more than 7 mm in 15 cases (58%) and more than 10 mm in 13 cases (50%); focal bulging of the diaphragma sellae in 16 cases (62%); erosion of the sellar floor in 20 cases (77%); deviation of the pituitary stalk in 19 cases (73%); and abnormal attenuation or enhancement of the pituitary gland in 18 cases (69%). Three patients (12%) showed no evidence of any abnormal CT finding despite a hyperprolactinemic state of over 200 ng/ml. Six histologically proven cases (23%) of prolactinomas and chromophobe adenomas showed radiologic evidence of cavernous sinus invasion. We conclude that patients with a serum prolactin level higher than 200 ng/ml generally show significant changes in the sella turcica in CT.

Long-term radiographic follow-up of the sella turcica in hyperprolactinaemic women

Seventy-three hyperprolactinaemic women were followed up with radiographic examinations (lateral and posteroanterior coned down views) of the sella turcica for 5 to 13 years during which time all but one had received treatment with bromocriptine. Progression of the sellar asymmetry occurred in 25 women (7 during pregnancy), 14 had regression of their changes in the pituitary fossa while 34 did not show any changes in the configuration of the sella turcica. Prolactin levels in serum, duration of bromocriptine therapy or sellar configuration could not predict later radiographic progressive or regressive changes of the sella turcica. The clinical course was benign in the majority of the women with signs of prolactin-producing adenomas. The risk of serious tumour enlargement seems to be very small. We were not able to demonstrate any parameter which could predict the growth or shrinkage of the tumour. Routinely repeated radiographic sellar examinations are unnecessary in the vast majority of hyperprolactinaemic women.

Pituitary computed tomography: is contrast enhancement necessary?

Direct coronal computed tomography of the pituitary fossa, before and after enhancement with intravenous contrast medium, was performed on 25 consecutive patients with hyperprolactinaemia. The images were viewed separately by two independent observers and the pituitary height, width and contour, and the visibility of the infundibulum, optic chiasm and hypothalamus were assessed. The presence and size of any possible pituitary tumour was recorded. The administration of intravenous contrast medium made no significant difference to the pituitary measurements, the visibility of the infundibulum of hypothalamus, or the detection of possible pituitary tumours. There was an inconsistent improvement in the visibility of the optic chiasm following enhancement. The arguments against an unenhanced examination are discussed and refuted. It is proposed that routine administration of intravenous contrast medium is unnecessary when investigating moderate hyperprolactinaemia.

Pituitary enlargement and hyperprolactinaemia due to primary hypothyroidism: errors and delays in diagnosis

Two young women with pituitary gland enlargement and hyperprolactinaemia were referred for pituitary surgery. Both had received bromocriptine (one patient for 13 years) for presumed prolactinoma. Mild clinical signs of hypothyroidism were present and endocrine tests revealed primary autoimmune thyroid failure. Following thyroxine replacement treatment, the pituitary enlargement and hyperprolactinaemia completely resolved. In both patients the hyperprolactinaemia was relatively mild and menorrhagia had been present for many years. A third patient, a 61-year-old man presenting with bitemporal hemianopia due to pituitary enlargement underwent transphenoidal pituitary surgery. The results of thyroid function tests on admission were not available until after surgery. Although the patient was clinically euthyroid, these revealed primary hypothyroidism and his considerable pituitary enlargement may also have been secondary to thyroid failure. Urgent thyroid function tests should be performed in all patients with pituitary enlargement prior to surgery to exclude hypothyroid induced pituitary swelling.

Pituitary gland enlargement in primary hypothyroidism: a report of 5 cases with follow-up data

Five female patients with primary hypothyroidism and radiological evidence of a pituitary enlargement were studied before and after a mean of 30 months (range 12-83 months) treatment with thyroxine (T4). Before treatment, serum thyroid-stimulating hormone (TSH) levels were elevated in every patient (mean 392 mU/l, range 240-475) and prolactin levels in 4 (mean 79 micrograms/l, range 48-143 micrograms/l). CT scanning confirmed the presence of pituitary enlargement in the 4 patients studied, which was suprasellar in 3. The remaining patient had an enlarged fossa on a lateral skull radiograph. During treatment with T4, TSH and prolactin levels were normal in all. Complete disappearance of the enlargement was seen on follow-up scans in all patients and 1 developed an empty sella. The induction of a pituitary enlargement by primary hypothyroidism results from reversible hyperplasia of both the TSH and prolactin-secreting cells in most instances. Occasionally, however, hyperplasia of the thyrotrophs can occur in isolation and an empty sella can occur after successful treatment with T4. Thyroid function tests should be obtained in all hyperprolactinemic patients.

Diagnostic work-up of hyperprolactinemic disorders

Substantial advances have been made in the understanding of chronic hyperprolactinemia. The diagnostic effort should be directed at excluding physiological and pharmacological causes of chronic hyperprolactinemia, both of which are reversible and are not likely to be of grave consequence. Subsequently further efforts should be made to rule out obvious pathological entities, in particular, treatable hypothyroidism. Finally, the diagnosis of prolactinoma must be entertained. It relies on the biochemical determination of prolactin as well as direct imaging of the pituitary.

Vertebral bone density in non-amenorrhoeic hyperprolactinaemic women

Recently, a decrease in bone mineral content (BMC) in hyperprolactinaemic women with long-lasting amenorrhoea has been reported, and attributed either to a direct effect of PRL on bone or secondary to the oestrogen deficiency. To verify if PRL by itself has a direct effect on bone, we have studied BMC at the lumbar level by double-photon absorptiometry in 22 patients with hyperprolactinaemia, selected on the basis of normal or near-normal oestradiol levels. The results were compared with those obtained in 28 healthy closely-matched women, and seven hyperprolactinaemic patients with long-lasting amenorrhoea and oestrogen deficiency. No significant difference in BMC was observed between hyperprolactinaemic patients with normal oestrogen levels (mean +/- SEM = 3.87 +/- 0.10 gHA/cm) and normal subjects (mean +/- SEM = 3.76 +/- 0.10 gHA/cm). Moreover, no significant change was observed during a 6 month follow-up in 13 patients. On the other hand, a significant difference (P less than 0.05) was detected in BMC between the hyperprolactinaemic patients with normal oestradiol levels and those with long-lasting amenorrhoea and oestrogen deficiency (mean +/- SEM = 3.39 +/- 0.18). These results suggest that hyperprolactinaemia by itself is not a risk factor for the development of osteoporosis.

Clinical, endocrine, roentgenographic, and immune characterization of hyperprolactinemic women

Seventy-one hyperprolactinemic women were analyzed for medical history, gonadotropin and ovarian hormonal levels, and prolactin (PRL) responsiveness to benserazide. Sellar tomography was then performed on a yearly basis for 3 years in all women, computerized coronal and sagittal tomography in 54 of them. Under basal conditions, 30 women had roentgenographic evidence of pituitary adenoma; at the end of the follow-up period, such evidence was seen in 44. Amenorrhea, steady PRL levels, a low LH/FSH ratio, a longer duration of the disease, and low serum progesterone levels were more common in women with a final diagnosis of pituitary adenoma than in those with a persistently normal sella. The benserazide test for PRL release had yielded abnormal results since the beginning in all the 44 women with final roentgenographic evidence of pituitary adenoma, and in about half of the patients with persistently normal aspect of the sella; autoantibodies towards the pituitary gland, the thyroid gland, and gastric parietal cells were found in 3, 2, and 3 patients, respectively. No autoantibodies towards the adrenal gland or the islets of Langerhans were ever found in any cases. These data show that a fair proportion of hyperprolactinemic women have a (micro)adenoma, which becomes apparent over a relatively short period of time. Amenorrhea and steadily raised PRL levels are more common in these women. The benserazide test seems to be adequate for predicting which women will eventually develop a roentgenographically detectable adenoma. Autoimmunity does not seem to be involved in the pathogenesis of hyperprolactinemia and/or pituitary adenoma.

High resolution computed tomography in the evaluation of hyperprolactinemia

High resolution computed tomography should eventually replace other imaging modalities in the evaluation of the pituitary gland in patients with endocrine disorders. In cooperative patients the intrasellar contents can be quickly and easily evaluated with minimal irradiation.

Nomifensine test does not differentiate hyperprolactinemia associated with and without radiologic abnormalities in the sella turcica

A group of 17 hyperprolactinemic women was given 200 mg of nomifensine orally to evaluate its diagnostic potential to discriminate between tumors and nontumorous hyperprolactinemia. The nomifensine suppressive effect on prolactin serum levels was not significantly different between patients with or without enlargement of the sella turcica. A control group of 5 women with normal prolactin levels exhibited a nomifensine suppressive effect below 65% of the baseline prolactin level, which was significantly different from that in the hyperprolactinemic group. In conclusion it is confirmed that the nomifensine test provides no value in the early diagnosis of the prolactinoma.