Hyperprolactinemia
Introduction
Introduction to hyperprolactinemia Hyperpro-lactinemia (HPRL) refers to a syndrome characterized by elevated internal and external environmental factors, elevated PRL (25 ng/ml), amenorrhea, galactorrhea, anovulation and infertility. In the past 20 years, the physiological and biochemical research on PRL has made great progress, and the advancement of PRL radioimmunoassay, brain CT and MRI diagnostic techniques has improved the diagnostic level of HPRL, and its incidence has also increased. At the same time, the advent of the antiprolactin drug Bromocriptine (Parlodel) and the development of transsphenoidal microsurgery have brought about a new situation in the diagnosis and treatment of HPRL. basic knowledge Sickness ratio: 0.0001% Susceptible people: good for adult women Mode of infection: non-infectious Complications: loss of libido migraine migraine headache edema acne acromegaly diabetes
Cause
Cause of hyperprolactinemia
Physiological hyperprolactinemia (30%):
(1) Night and sleep (2~6Am). (2) Late egg stage and luteal phase. (3) Pregnancy: 10 times higher than non-pregnancy. (D) lactation: by massage, nipple sucking caused by acute, short-term or sustained secretion increased. (5) puerperium period: 3 to 4 weeks. (6) Low blood sugar. (7) Exercise and stress stimulation. (8) Sexual intercourse: significantly increased during orgasm. (9) Fetus and newborn ( 28 weeks of gestation ~ 2 to 3 weeks after delivery).
Pathological hyperprolactinemia (25%):
(a) hypothalamic-pituitary lesions 1, tumors: non-functional - craniopharyngioma, sarcoid-like disease (sarcoid) glioma. Functionality - PRL adenoma 46%; GH adenoma 22 ~ 31%, PRL-GH adenoma 5 ~ 7%; ACTH adenoma & Nelsons syndrome 4 ~ 15%, multi-functional adenoma 10%; undifferentiated tumor 19 ~ 27 %.
2, inflammation: skull base meningitis, tuberculosis, syphilis, actinomycosis.
3. Destruction: injury, surgery, venous malformation, granulomatosis (Hand-Schüller-Christians syndrome).
4, vacuole Sella syndrome.
5, pituitary stalk lesions, injury or tumor compression.
6. Trauma and stress.
7, Parkinson's disease.
(B) primary and / or secondary hypothyroidism.
1, pseudo-parathyroidism (Pseudo-parathyroidism).
2. Hashimotos thyroiditis.
(C) ectopic PRL secretion syndrome: undifferentiated bronchogenic carcinoma, adrenal cancer, embryonic cancer.
(D) Adrenal and kidney disease: Addison's disease, chronic renal failure.
(5) Polycystic ovary syndrome.
(6) Cirrhosis of the liver.
(7) Obstetrics and Gynecology Surgery: induced abortion, induced labor, stillbirth, hysterectomy, tubal ligation, oophorectomy.
(8) Local irritation: papillitis, cleft palate, chest wall trauma, herpes zoster, tuberculosis, surgery.
(9) Medical source - drug factors:
1, insulin hypoglycemia.
2, sex hormones (female-progestin contraceptives).
3. Synthesis of TSH-RH.
4. Anesthetics: morphine, methadone, methionine enkephalin.
5. Dopamine receptor blockers: Phenothiazones, Haloperidol, Metoclprimide, Domperidone, Pimozide, Sulpiride.
6, dopamine reuptake blocker: Nomifensine.
7, CNS dopamine degradation agent: Reserpine, amethyl-Dopa.
8, dopamine conversion inhibitor: a peptide.
9. Monoamine oxidase inhibitors.
10, diphenyl nitrogen derivatives: dibenzoxazole nitrogen, carbamoyl nitrogen, due to swell, imipramine, amitriptyline, phenytoin and chlordiazepine Clonazepam.
11. Histamine and histamine H1, H2, receptor antagonists: serotonin, Amphetamines, Hallucinogens, H1 receptor antagonists (mestrozine meclizine, pyridazine, Pyrribenzamine), H2 receptor antagonist (cyanide) Cimitidine).
Prevention
Hyperprolactinemia prevention
1, amenorrhea external treatment of self-therapy: 1500 grams of scented paulownia skin, 90 grams of Awei, first add the scented paulownia skin with water to extract the juice, add the wormwood into a paste, coated on a inch of square gauze, posted on the off Yuanyuan is applied for 2-3 days for a course of treatment. Guanyuan Point: 3 inches in the middle of the umbilicus, white pepper, yellow dan, 9 grams of fire and nitrate, a total of research and fine, made 3 cake heads, each take 1 sticker Under the umbilicus, change one after 24 hours, use for 3 days, 2 grams of fragrant scent, 1 gram of peach kernel, 1 leeches, and the prodrug is mixed with water to form a paste, applied to the umbilicus, and the external wound is wet and painful. Cream, 2-3 days for 1 time, Puhuang, Wulingzhi, 2 grams of pangolin, a total of research, applied to the wound and painkiller paste, attached to the umbilicus.
2, amenorrhea family treatment measures: diet should avoid dairy products: yogurt, dairy products, sugar, meat easily cause skin fever, so diet should try to avoid dairy products.
3, you can eat more lettuce, kelp, squid (including bone), sardines, etc., should eat less meals: eat less meals is beneficial to the body to regulate body temperature.
4. Decrease caffeine and alcohol: Alcohol-containing beverages will stimulate certain hormone secretions and induce skin fever.
[Life Health]
1, drink plenty of water: drink plenty of water or juice, you can also effectively control body temperature.
2, optimistic face to life: Although women around the age of 50 may face many new problems, such as children grow up to become a family, may bring some loneliness, but still can live a full life in this period, such as may wish to go to school Learn what you want to learn when you are young and have no time to learn, or do some sports you like, walking, jogging, cycling, dancing, skipping, swimming, etc. These are good choices, which will make people feel good and forget. upset.
3, to maintain a regular sex life: regular sexual life is not easy to make the skin fever, and can indirectly stimulate the degenerate ovary, to ease the hormonal system, and prevent estrogen sharp decline.
[Prevention of amenorrhea attention]
1, enhance physical fitness, improve health, usually strengthen physical exercise, often used for health gymnastics or Tai Chi.
2, to avoid mental stimulation, to stabilize the mood, to maintain blood and smooth, menstrual period should pay attention to keep warm, especially below the waist, the two feet are not cold, not involved in cold water, and fasting cold fruits.
3, menstrual body resistance is weak, avoid heavy physical labor, pay attention to work and rest, coordination, rushing to qi and blood, menstrual dissatisfaction with cold medicine, strengthen nutrition, pay attention to the spleen and stomach, in the case of good appetite, can eat more meat, eggs Classes, milk and fresh vegetables, do not eat spicy food.
4, remove chronic lesions, breastfeeding should not be too long, cautiously engaged in artificial abortion, correct control of oral contraceptives, obese patients should appropriately limit diet and water and salt intake.
Complication
Hyperprolactinemia complications Complications libido migraine migraine headache edema acne acromegaly diabetes
(A) low estrogen response: seen in long-term amenorrhea, such as flushing, palpitations, spontaneous sweating, vaginal dryness, sexual pain, loss of libido.
(B) visual acuity and visual field changes: seen in the pituitary tumor involving the optic nerve cross, there may be vision loss, headache, dizziness, hemianopia and blindness, as well as cranial nerve II, III, IV dysfunction, fundus edema, exudation.
(C) high androgen response: moderate obesity, seborrheic, acne hairy.
(4) Acromegaly: When seen in PRL-GH adenoma, GH is elevated.
(5) Mucinous edema: seen in the case of combined hypothyroidism.
(6) Abnormalities in diabetes and glucose tolerance tests.
Symptom
Hyperprolactinemia symptoms Common symptoms galactorrhea menstruation rare masculinized edema amenorrhea large breast 21-hydroxylase deficiency secondary amenorrhea polycystic ovary diabetes
First, menstrual disorders
Primary amenorrhea 4%, secondary amenorrhea 89%, menstrual scarcity, too little 7%, dysfunctional uterine bleeding, luteal function is not healthy 23 to 77%.
Second, galactorrhea
The typical HPRL is characterized by amenorrhea-galactorrhea syndrome, which is 20.84% in non-tumor type, 70.58% in tumor type, and 63-83.55% in simple galactorrhea. When galactorrhea is dominant or squeezed breast, it is watery and serous. Or milk, more normal breasts, or with lobular hyperplasia or macromassia.
Third, infertility
70.71% primary or secondary, caused by anovulation, luteal insufficiency or luteinized non-ruptured follicular syndrome (LUFS).
Examine
Hyperprolactinemia test
1. Sella fault:
Normal women's saddles have a anteroposterior diameter of <17mm, a depth of <13mm, an area of <130mm2, and a volume of <1100mm3. If there is a scene like the following: CT: 1 ballooning; 2 double saddle bottom or double floors; 3 saddle high/low density area or inhomogeneity; 4 plate deformation (saucer, like pattern); 5 saddle upper calcification (hyperostosis); 6 anterior and posterior bed osteoporosis or saddle vacuolization; 7 bone Destruction (erosion).
Second, electronic computed tomography (CT) and nuclear magnetic resonance (MRI):
Accurate localization and radiometric measurement of intracranial lesions.
Third, angiography:
These include: intercavernous sinus venography, pneumoencephalography and vasoencephalography.
Fourth, endocrine function check:
(1) Pituitary function: FSH, LH decreased, LH/FSH ratio increased, PRL increased 25ng/ml, it is generally considered that <100ng/ml is mostly functional, 100mg/ml should be excluded to exclude PRL adenoma, the more the tumor The higher the PRL, the higher the tumor diameter d5mm, the PRL is 171±38ng/ml; the d=510mm 206±29ng/ml; 10mm485±158ng/ml, the PRL may not increase when the adenoma is hemorrhagic and necrotic, need It is pointed out that the current clinical PRL radiology kit only measures small molecule PRL (MW25000), but can not measure large/large molecule (MW5100000) PRL, so some clinical symptoms are obvious and PRL is normal, so-called occult high lactation can not be ruled out. Occult hyperprolactinemia, ie large/large molecule hyperprolactinemia.
(B) ovarian function test: E2, P decreased, T increased.
(C) thyroid function test: HPRL combined with hypothyroidism increased TSH, T3, T4, PBI decreased.
(D) Adrenal function test: When HPEL combined with Cushing's disease and masculinization, T, 4dione, DHT, DHEA, 17KS increased, plasma cortisol increased.
(5) Pancreatic function test: HPRL combined with diabetes, acromegaly, insulin, blood glucose, glucagon and glucose tolerance test should be measured.
5. Prolactin function test:
(1) Prolactin stimulation test:
1, thyrotropin releasing hormone test (TRHtest): normal women once intravenous injection TRH100 ~ 400g, 15 ~ 30 minutes PRL increased 5 to 10 times before injection, TSH increased 2 times, pituitary tumors do not rise .
2, Chlorpromazine test (Chlorpromazine test): Chlorpromazine by receptor transfer, inhibition of norepinephrine absorption and conversion of dopamine function, promote PRL secretion, normal women intramuscular injection of 25 ~ 50mg 60 ~ 90 minutes after blood PRL It is 1 to 2 times higher than that before injection, lasting for 3 hours, and it is not elevated when the pituitary tumor is present.
3. Metoclopramide test: This drug is a dopamine receptor antagonist to promote the synthesis and release of PRL. In normal women, 30 to 60 minutes after intravenous injection of 10 mg, PRL is more than 3 times higher than that before injection. Not rising.
(2) Prolactin inhibition test:
1. L-Dopa test: This drug is a dopamine precursor, which produces DA by dehydroxylase and inhibits PRL secretion. In normal women, PRL is significantly decreased 2 to 3 hours after oral administration of 500 mg, and pituitary tumors are not. reduce.
2, Bromocriptine test (Bromocriptine test): This drug is a dopamine receptor agonist, strong inhibition of PRL synthesis and release, normal women after oral administration of 2.5 ~ 5.0mm 2 to 4 hours after PRL reduction 50%, lasting 20 to 30 hours The functional HPRL and PRL adenomas decreased significantly, while the GH and ACTH decreased less than the former two.
Sixth, ophthalmic examination:
Including vision, visual field, intraocular pressure, fundus examination to determine whether there is intracranial tumor compression.
Diagnosis
Diagnosis and identification of hyperprolactinemia
diagnosis
First, medical history
Focus on the history of menstruation, marriage and childbirth, the origin of amenorrhea and galactorrhea, causes, systemic diseases and history of HPRL-related drug treatment.
Second, check the body
Physical examination, attention to the presence or absence of acromegaly, mucinous edema, gynecological examination to understand the genital and sexual signs with or without atrophy and organic lesions, breast examination attention to size, morphology, with or without lumps, inflammatory galactorrhea (hands light Squeeze the breast), spill traits and quantity.
Third, endocrine function check
(1) Pituitary function: FSH, LH decreased, LH/FSH ratio increased, PRL increased 25ng/ml, it is generally considered that <100ng/ml is mostly functional, 100mg/ml should be excluded to exclude PRL adenoma, the more the tumor The higher the PRL, the higher the tumor diameter d5mm, the PRL is 171±38ng/ml; the d=510mm 206±29ng/ml; 10mm485±158ng/ml, the PRL may not increase when the adenoma is hemorrhagic and necrotic, need It is pointed out that the current clinical PRL radiology kit only measures small molecule PRL (MW25000), but can not measure large/large molecule (MW5100000) PRL, so some clinical symptoms are obvious and PRL is normal, so-called occult high lactation can not be ruled out. Occult hyperprolactinemia, ie large/large molecule hyperprolactinemia.
(B) ovarian function test: E2, P decreased, T increased.
(C) thyroid function test: HPRL combined with hypothyroidism increased TSH, T3, T4, PBI decreased.
(D) Adrenal function test: When HPEL combined with Cushing's disease and masculinization, T, 4dione, DHT, DHEA, 17KS increased, plasma cortisol increased.
(5) Pancreatic function test: HPRL combined with diabetes, acromegaly, insulin, blood glucose, glucagon and glucose tolerance test should be measured.
Fourth, prolactin function test
(a) prolactin stimulation test
1, thyrotropin releasing hormone test (TRHtest): normal women once intravenous injection TRH100 ~ 400g, 15 ~ 30 minutes PRL increased 5 to 10 times before injection, TSH increased 2 times, pituitary tumors do not rise .
2, Chlorpromazine test (Chlorpromazine test): Chlorpromazine by receptor transfer, inhibition of norepinephrine absorption and conversion of dopamine function, promote PRL secretion, normal women intramuscular injection of 25 ~ 50mg 60 ~ 90 minutes after blood PRL It is 1 to 2 times higher than that before injection, lasting for 3 hours, and it is not elevated when the pituitary tumor is present.
3. Metoclopramide test: This drug is a dopamine receptor antagonist to promote the synthesis and release of PRL. In normal women, 30 to 60 minutes after intravenous injection of 10 mg, PRL is more than 3 times higher than that before injection. Not rising.
(2) Prolactin inhibition test
1. L-Dopa test: This drug is a dopamine precursor, which produces DA by dehydroxylase and inhibits PRL secretion. In normal women, PRL is significantly decreased 2 to 3 hours after oral administration of 500 mg, and pituitary tumors are not. reduce.
2, Bromocriptine test (Bromocriptine test): This drug is a dopamine receptor agonist, strong inhibition of PRL synthesis and release, normal women after oral administration of 2.5 ~ 5.0mm 2 to 4 hours after PRL reduction 50%, lasting 20 to 30 hours The functional HPRL and PRL adenomas decreased significantly, while the GH and ACTH decreased less than the former two.
Differential diagnosis
Must be associated with acromegaly, acute renal failure, erectile dysfunction, herpes zoster, hypothyroidism, large pituitary adenoma, pituitary microadenomas, prolactinoma, alcoholic cirrhosis, pregnancy, postpartum, nipple irritation, non-fasting Specimens, drug effects, post-epileptic status, chest tumors, chest trauma and other diseases.
