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{{Prolactinoma}}
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==Overview==
==Overview==
A '''prolactinoma''' is a [[benign]] [[tumor]] ([[adenoma]]) of the '''[[pituitary gland]]''' that produces [[prolactin]]. It is the most common type of [[pituitary tumor]].  Symptoms of prolactinoma are caused by either [[hyperprolactinemia]] or by pressure of the tumor on surrounding tissues. In women, these [[adenomas]] are often small (<10 mm). In either sex, however, they can become large enough to enlarge the [[sella turcica]].  These adenomas represent the most common hormone-producing pituitary tumors and account for 25% to 41% of tumor specimens.<ref>http://www.cancer.gov/types/pituitary/hp/pituitary-treatment-pdq#link/_169_toc</ref>
A prolactinoma is a [[benign]] [[tumor]] ([[adenoma]]) of the [[pituitary gland]] that produces [[prolactin]]. It is the most common type of [[pituitary tumor]].  Symptoms of prolactinoma are caused either by [[hyperprolactinemia]] or by pressure of the tumor on surrounding tissues. In women, these [[adenomas]] are often small (<10 mm). In either sex, however, they can become large enough to enlarge the [[sella turcica]].  These adenomas represent the most common [[hormone]]-producing [[pituitary tumors]] and account for 45% of all [[pituitary tumors]]. [[MRI]] is the most sensitive diagnostic test for detecting [[pituitary tumors]] (including [[prolactinoma]]). Medical therapy for prolactinoma includes [[dopamine]] agonists. Surgery is indicated in patients if medical therapy cannot be tolerated. Transsphenoidal resection of the tumor is rarely done among patients with [[prolactinoma]] as most of the patients respond to medical management.


==Historical Perspective==
==Historical Perspective==


[[Pituitary]] tumor was officially described by Pierre Marie, a French neurologist (Salpetriere Hospital, Paris).
In 1970, [[prolactin]] was discovered in humans by sensitive [[bioassay]]. In 1978, V C Medvei, the President of the Section of History of Medicine (1986-87) of the Royal Society of Medicine in London, wrote in his paper that Queen Mary I of England was believed to have prolactinoma.


==Classification==
==Classification==
 
[[Prolactinoma]] can be classified based either on size or local invasion. Based on size, a prolactinoma can be classified as a microprolactinoma (<10 mm diameter) or macroprolactinoma (>10 mm diameter).
Prolactinoma may be classified according to size or location.


==Pathophysiology==
==Pathophysiology==
[[Prolactinoma]] is the most common type of [[pituitary adenoma]]. [[Prolactinoma]] may occur in approximately 30% of [[multiple endocrine neoplasia type 1]] patients. It may also occur with [[Carney complex]] or [[McCune-Albright syndrome]]. There are a few reports of [[familial]] cases of [[prolactinoma]] unrelated to [[Multiple endocrine neoplasia type 1|MEN 1 syndrome]]. [[Prolactinoma]] is also associated with various [[familial]] syndromes. On gross pathology, [[prolactinoma]] is divided on the basis of size into microprolactinoma and macroprolactinoma. On [[histological]] analysis, [[prolactinoma]] may be divided into sparsely granulated and densely granulated prolactinomas.


[[Prolactinoma]] may occur as part of a hereditary disorder called multiple endocrine neoplasia type 1 (MEN 1), so patients with MEN 1 are at incresead risk for prolactinoma. A minority of tumors are associated with multiple endocrine neoplasia type I (MEN I), Carney complex, McCune-Albright Syndrome, MEN like syndrome ( CKDN1B loss of function).<ref>http://radiopaedia.org/articles/pituitary-adenoma</ref>
==Causes==
There are no established causes for [[prolactinoma]]. Most cases of [[prolactinoma]] are sporadic. [[Prolactinoma]] may occur in approximately 30% of [[multiple endocrine neoplasia type 1]] patients. It may also occur with [[Carney complex]] or [[McCune-Albright syndrome]].


==Prolactinoma and Pregnancy==
== Differentiating prolactinoma from other diseases ==
Women with prolactin-secreting tumors may experience further [[pituitary]] enlargement and must be closely monitored during pregnancy. However, damage to the pituitary or [[optic]] nerve occurs in less than one percent of pregnant women with [[prolactinoma]]. In women with large tumors, the risk of damage to the [[pituitary]] or [[optic]] nerve is greater, and some physicians consider it as high as 25%.
[[Prolactinoma]] must be differentiated from other causes of [[hyperprolactinemia]] that may also present as [[galactorrhea]], [[amenorrhea]], (in females) and [[infertility]] (in both males and females). Causes of [[hyperprolactinemia]] can be categorized as [[physiological]], [[pathological]], and [[medication-induced]].


==Causes==
It has been shown that stress can significantly raise [[prolactin]] levels which should make stress a diagnostic differential though it usually is not considered such. Most [[pituitary]]  tumors are sporadic--they are not genetically passed from parents to offspring.
==Epidemiology and Demographics==
==Epidemiology and Demographics==
[[Autopsy]] studies indicate that 6-25% of the U. S. population have small [[pituitary tumors]]. Forty percent of these pituitary tumors produce prolactin, but most are not considered clinically significant. Clinically significant pituitary tumors affect the health of approximately 14 out of 100,000 people in United States.
45% of [[Pituitary adenoma|pituitary adenomas]] are [[prolactinomas]], making it the most common type of all [[Pituitary adenoma|pituitary adenomas]]. Worldwide, the prevalence of sporadic [[prolactinoma]] is 6 to 10 per 100,000 persons. The prevalence of [[prolactinoma]] in people less than 20 years old is 10 per 100,000 individuals worldwide. [[Prolactinoma]] most commonly affects women in reproductive age group (20 to 50 years). [[Prolactinoma]] is more common in females than males in people between 20 and 50 years old. Frequency becomes similar after age 50.


==Risk Factors==
==Risk Factors==
[[Prolactinoma]] may occur as part of a hereditary disorder called multiple endocrine neoplasia type 1 (MEN 1), so patients with MEN 1 are at incresead risk for prolactinoma.  
There are no established risk factors for [[prolactinoma]]. Some conditions increase the risk of [[prolactinoma]], such as [[multiple endocrine neoplasia type 1]] ([[MEN 1]]), [[Carney complex]], [[McCune-Albright Syndrome|McCune-Albright syndrome]], familial isolated [[pituitary adenoma]], and MEN 1 like [[syndrome]].  
==Differentiating prolactinoma from other diseases==
 
Prolactinoma causes hyperprolactinemia which must be differentiated from hypothyroidism and effects of medications(antipsychotics and antidepressants).
== Screening ==
There is insufficient evidence to recommend routine [[Screening (medicine)|screening]] for [[prolactinoma]].


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
[[Hyperprolactinemia]] can cause reduced [[estrogen]] production in women and reduced [[testosterone]] production in men.People with [[microprolactinoma]] generally have an excellent [[prognosis]]. In 95% of cases the tumor will not show any signs of growth after a 4 to 6 year period. Macroprolactinomas often require more aggressive treatment otherwise they may continue to grow.  There is no way to reliably predict the rate of growth, as it is different for every individual.  Regular monitoring by a specialist to detect any major changes in the [[tumor]] is recommended.
If left untreated, 95% of cases of [[prolactinoma]] will not show any [[signs]] of [[growth]] during the first 4 to 6 years. Complications of [[prolactinoma]] include [[pituitary apoplexy]] and [[vision loss]]. [[Prognosis]] is generally excellent for cases of microprolactinoma.


==History and Symptoms==
==History and Symptoms==
The symptoms experienced by women and men are as for [[hyperprolactinemia]] from all causes.
Common [[symptoms]] of [[prolactinoma]] include [[headache]], vision changes, decreased [[libido]], [[infertility]], and [[osteoporosis]]. In women, common [[symptoms]] of [[prolactinoma]] include [[breast]] tenderness, [[galactorrhea]], and [[amenorrhea]] or [[oligomenorrhea]].  
 
==Physical Examination==
==Physical Examination==
In addition to assessing the size of the pituitary [[tumor]] and damage to surrounding tissues it is necessary to perform tests to assess whether production of other pituitary hormones is normal. Depending on the size of the tumor, the physician may request an eye exam with measurement of [[visual]] fields.
Patients with [[prolactinoma]] generally appear healthy. The most common [[physical examination]] finding of [[prolactinoma]] is [[visual field]] defects ([[bitemporal hemianopsia]]).


==Laboratory Findings==
==Laboratory Findings==
Prolactin blood levels are tested in women with unexplained milk secretion ([[galactorrhea]]) or irregular [[menses]] or [[infertility]], and in men with impaired sexual function and, in rare cases, milk secretion.
Laboratory findings consistent with the diagnosis of [[prolactinoma]] include markedly elevated [[prolactin]] levels.
 
==ECG==
There are no [[ECG]] findings associated with [[prolactinoma]].
 
==X-ray==
There are no [[X-ray]] findings associated with [[prolactinoma]].
 
==Ultrasound==
There are no [[ultrasound]] findings associated with [[prolactinoma]].  
 
==CT Scan==
==CT Scan==
[[Computed Tomography]] (CT scan) is used to visualize changes in the pituitary region of the brain. But it is less sensitive than [[MRI]].
[[CT scan]] of head is usually normal in patient of [[prolactinoma]]. Sometimes, enlargement of [[sella turcica]] may be found in case of macroprolactinoma.
 
==MRI==
==MRI==
Magnetic resonance imaging ([[MRI]]), is the most sensitive test for detecting pituitary tumors and determining their size. [[MRI]] scans may be repeated periodically to assess [[tumor]] progression and the effects of therapy. MRI is more sensitive than CT in detecting [[pituitary]] tumors.
[[MRI]] may be diagnostic of [[prolactinoma]]. [[Magnetic resonance imaging]] ([[MRI]]) is the most sensitive test for detection of [[pituitary tumors]] and determination of their size.


==Medical Therapy==
==Medical Therapy==
Medical therapy for prolactinoma includes [[dopamine agonists]] (either [[cabergoline]] or [[bromocriptine]]). The goal of treatment is to return [[prolactin]] secretion to normal, reduce [[tumor]] size, correct any [[visual]] abnormalities, and restore normal [[pituitary]] function.


The goal of treatment is to return [[prolactin]] secretion to normal, reduce tumor size, correct any [[visual]] abnormalities and restore normal pituitary function. As mentioned above, the impact of stress should be ruled out before the diagnosis of prolactinoma is given.  Exercise can significantly reduce stress and, thereby, [[prolactin]] levels.  It should also be noted that higher prolactin levels may contribute to the development of prolactinomas so the [[diagnosis]] can be self-fulfilling if the original cause is stress. In the case of very large [[tumors]], only partial reduction of the prolactin levels may be possible.
==Surgery==
Surgery is not the first-line treatment option for patients with [[prolactinoma]]. [[Surgery]] is usually reserved for patients whose medical therapy fails to reduce the size of the [[tumor]].


==Surgery==
==Primary prevention==
[[Surgery]] should be considered if medical therapy cannot be tolerated or if it fails to reduce [[prolactin]] levels, restore normal reproduction and [[pituitary]] function, and reduce tumor size.  If medical therapy is only partially successful, this therapy should continue, possibly combined with surgery or [[radiation]] treatment.
There is no established method for [[primary prevention]] of [[prolactinoma]].
 
==Secondary prevention==
There is no established method for [[secondary prevention]] of [[prolactinoma]].  


== References ==
== References ==
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Latest revision as of 23:50, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2], Faizan Sheraz, M.D. [3]

Overview

A prolactinoma is a benign tumor (adenoma) of the pituitary gland that produces prolactin. It is the most common type of pituitary tumor. Symptoms of prolactinoma are caused either by hyperprolactinemia or by pressure of the tumor on surrounding tissues. In women, these adenomas are often small (<10 mm). In either sex, however, they can become large enough to enlarge the sella turcica. These adenomas represent the most common hormone-producing pituitary tumors and account for 45% of all pituitary tumors. MRI is the most sensitive diagnostic test for detecting pituitary tumors (including prolactinoma). Medical therapy for prolactinoma includes dopamine agonists. Surgery is indicated in patients if medical therapy cannot be tolerated. Transsphenoidal resection of the tumor is rarely done among patients with prolactinoma as most of the patients respond to medical management.

Historical Perspective

In 1970, prolactin was discovered in humans by sensitive bioassay. In 1978, V C Medvei, the President of the Section of History of Medicine (1986-87) of the Royal Society of Medicine in London, wrote in his paper that Queen Mary I of England was believed to have prolactinoma.

Classification

Prolactinoma can be classified based either on size or local invasion. Based on size, a prolactinoma can be classified as a microprolactinoma (<10 mm diameter) or macroprolactinoma (>10 mm diameter).

Pathophysiology

Prolactinoma is the most common type of pituitary adenoma. Prolactinoma may occur in approximately 30% of multiple endocrine neoplasia type 1 patients. It may also occur with Carney complex or McCune-Albright syndrome. There are a few reports of familial cases of prolactinoma unrelated to MEN 1 syndrome. Prolactinoma is also associated with various familial syndromes. On gross pathology, prolactinoma is divided on the basis of size into microprolactinoma and macroprolactinoma. On histological analysis, prolactinoma may be divided into sparsely granulated and densely granulated prolactinomas.

Causes

There are no established causes for prolactinoma. Most cases of prolactinoma are sporadic. Prolactinoma may occur in approximately 30% of multiple endocrine neoplasia type 1 patients. It may also occur with Carney complex or McCune-Albright syndrome.

Differentiating prolactinoma from other diseases

Prolactinoma must be differentiated from other causes of hyperprolactinemia that may also present as galactorrhea, amenorrhea, (in females) and infertility (in both males and females). Causes of hyperprolactinemia can be categorized as physiological, pathological, and medication-induced.

Epidemiology and Demographics

45% of pituitary adenomas are prolactinomas, making it the most common type of all pituitary adenomas. Worldwide, the prevalence of sporadic prolactinoma is 6 to 10 per 100,000 persons. The prevalence of prolactinoma in people less than 20 years old is 10 per 100,000 individuals worldwide. Prolactinoma most commonly affects women in reproductive age group (20 to 50 years). Prolactinoma is more common in females than males in people between 20 and 50 years old. Frequency becomes similar after age 50.

Risk Factors

There are no established risk factors for prolactinoma. Some conditions increase the risk of prolactinoma, such as multiple endocrine neoplasia type 1 (MEN 1), Carney complex, McCune-Albright syndrome, familial isolated pituitary adenoma, and MEN 1 like syndrome.

Screening

There is insufficient evidence to recommend routine screening for prolactinoma.

Natural History, Complications and Prognosis

If left untreated, 95% of cases of prolactinoma will not show any signs of growth during the first 4 to 6 years. Complications of prolactinoma include pituitary apoplexy and vision loss. Prognosis is generally excellent for cases of microprolactinoma.

History and Symptoms

Common symptoms of prolactinoma include headache, vision changes, decreased libido, infertility, and osteoporosis. In women, common symptoms of prolactinoma include breast tenderness, galactorrhea, and amenorrhea or oligomenorrhea.

Physical Examination

Patients with prolactinoma generally appear healthy. The most common physical examination finding of prolactinoma is visual field defects (bitemporal hemianopsia).

Laboratory Findings

Laboratory findings consistent with the diagnosis of prolactinoma include markedly elevated prolactin levels.

ECG

There are no ECG findings associated with prolactinoma.

X-ray

There are no X-ray findings associated with prolactinoma.

Ultrasound

There are no ultrasound findings associated with prolactinoma.

CT Scan

CT scan of head is usually normal in patient of prolactinoma. Sometimes, enlargement of sella turcica may be found in case of macroprolactinoma.

MRI

MRI may be diagnostic of prolactinoma. Magnetic resonance imaging (MRI) is the most sensitive test for detection of pituitary tumors and determination of their size.

Medical Therapy

Medical therapy for prolactinoma includes dopamine agonists (either cabergoline or bromocriptine). The goal of treatment is to return prolactin secretion to normal, reduce tumor size, correct any visual abnormalities, and restore normal pituitary function.

Surgery

Surgery is not the first-line treatment option for patients with prolactinoma. Surgery is usually reserved for patients whose medical therapy fails to reduce the size of the tumor.

Primary prevention

There is no established method for primary prevention of prolactinoma.

Secondary prevention

There is no established method for secondary prevention of prolactinoma.

References


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