galactorrhea-amenorrhea syndrome
Introduction
Introduction to galactorrhea-menopausal syndrome Seborrheic amenorrhea syndrome refers to the syndrome of non-postpartum women who have amenorrhea and have breast milk, or postpartum women who stop breastfeeding for half a year and continue to have amenorrhea and lactation. In 1951, Forbes and Albringt first reported. basic knowledge The proportion of illness: 0.001% Susceptible people: women Mode of infection: non-infectious Complications: amenorrhea
Cause
The cause of galactorrhea-menopausal syndrome
(1) Causes of the disease
Since the detection of prolactin (PRL) by radioimmunoassay in the 1970s, this syndrome has been thought to be caused mainly by abnormally elevated PRL in the blood.
1. Drug-induced: Some drugs that consume hypothalamic dopamine (DA) or block DA can increase PRL, and phenothiazine-based sedatives such as chlorpromazine, perphenazine, sulpiride, etc., acting on the central nervous system, Antiemetics such as metoclopramide (metaclopramide) can directly bind to dopamine receptors, consume dopamine, block the action of dopamine, and promote the secretion and release of PRL.
Antihypertensive drugs such as reserpine (reserpine), methyldopa, etc., promote the synthesis and release of norepinephrine, depletion of dopamine, leading to excessive secretion of PRL; cocaine, cimetidine and the like can inhibit the conversion of dopamine, The PRL is elevated, long-term use of estrogen and oral contraceptives, or some women are too sensitive to its effects, affecting the proliferation and secretion of pituitary prolactin cells, resulting in increased PRL.
2. Postpartum galactorrhea - amenorrhea: maternal continued lactation after weaning, amenorrhea, accompanied by ovarian function decline, uterine atrophy and other symptoms, the cause may be neurocrine dysfunction before delivery, unreasonable feeding after childbirth, etc., aggravation Hypothalamic-pituitary-ovarian dysfunction.
3. Non-postpartum galactorrhea - amenorrhea: caused by hypothalamic-pituitary organic lesions.
(1) Hypothalamic disorders: tumors in the hypothalamus or adjacent sites, hypothalamic inflammation or destructive lesions, head trauma, etc., affecting the secretion or transport of PRIF.
(2) pituitary tumors: 20% to 30% of hyperprolactinemia confirmed pituitary tumors.
(3) Empty sella syndrome: due to congenital dysplasia, or due to trauma, surgery, defects in the sphenoid sac, arachnoid formation of sputum, into the sella, compression of the pituitary and pituitary stalk, causing transport DA to be affected, so that serum In the middle of PRL, amenorrhea and galactorrhea occur.
(4) extracorporeal tumors: such as sarcoma, aneurysm, lymphoma, pineal tumor, ganglionoma can also increase prolactin secretion.
4. Idiopathic galactorrhea-menopausal syndrome: The cause of this sign is not due to hypothalamic-pituitary dysfunction; it may also be due to pituitary microadenomas being too small to be detected by modern radiological techniques.
5. Primary hypothyroidism: When the thyroid function is low, the hypothalamic thyrotropin releasing hormone (TRH) is secreted in a large amount, and the secretion of pituitary thyrotropin (TSH) is increased. TRH can also act on the secretion of pituitary prolactin cells, resulting in serum. In the middle of PRL, galactorrhea appears.
6. Other:
(1) Chronic renal failure: serum prolactin is excreted by the kidney. When the kidney is dysfunctional, the serum PRL rises, and the adrenal gland in the animal can cause high PRL. It is reported that patients with adrenal dysfunction have high PRL. After giving corticosteroid replacement therapy, blood PRL can return to normal.
(2) cirrhosis: 5% to 20% due to ethanol or non-ethanol, cirrhosis, 50% of patients with hepatic encephalopathy, elevated PRL, may be due to defects in the hypothalamic DA.
(3) various stress states: such as surgery, anesthesia, exercise, trauma, sucking nipples, venipuncture, sexual intercourse, pelvic examination, etc., can stimulate the elevation of PRL, and other breast stimulation, breast stimulation or Chest surgery, shingles through the spinal cord, can release excess PRL.
(4) ectopic prolactin (PRL) secretion: very rare, bronchial and renal cancer, may cause transcriptional initiation of PRL gene due to mutated cancer cells, secreting a large amount of PRL, in addition, ovarian teratoma contains ectopic pituitary tissue When the PRL can be raised.
(two) pathogenesis
The secretion and release of prolactin is regulated by two hormones in the hypothalamus. One is prolactin release inhibitor (PRIF), which acts on the pituitary gland to inhibit prolactin secretion, and the other is thyrotropin-releasing hormone. (TRH), which promotes the secretion of thyrotropin (TSH) from the pituitary, on the other hand, prolactin-releasing factor (PRF) activity, which promotes prolactin secretion in the pituitary, and substances such as catecholamines and dopamine Both can increase or increase the secretion of PRIF.
Any factor inhibiting the secretion of PRIF or promoting the activity of prolactin releasing factor can lead to an increase in PRL in the blood. PRL directly acts on the prolactin receptor of the mammary gland to stimulate milk production and secretion, while PRL is inhibited by feedback. The secretion of pituitary gonadotropins causes ovarian dysfunction, leading to amenorrhea.
Prevention
Breast overflow - amenorrhea prevention
Early detection, timely treatment, to prevent the development of the disease.
Complication
Seborrheic-menopausal complications Complications amenorrhea
A small number of patients have psychiatric symptoms.
Symptom
Symptoms of galactorrhea -menopausal syndrome Common symptoms Amenorrhea due to visual impairment of intracranial space-occupying lesions
1. Patients often have varying degrees of obesity, hairy and seborrhea, some patients may have mild acromegaly, but the internal organs do not increase, the soft tissue of the hands does not thicken.
2. galactorrhea is the earliest symptom, most of which are intermittent, but also persistent. The amount of galactorrhea is generally less. When the breast is squeezed, a small amount of white milk is dripping out. The patient's breast is full, no tenderness, and there is galactorrhea. Most patients have amenorrhea, but some patients may have amenorrhea without galactorrhea.
3. Amenorrhea is persistent. For example, in the pre-puberty period, the primary amenorrhea is accompanied by secondary sexual assault. In adult women, the symptoms are uterine atrophy, sexual dysfunction, and infertility.
4. Other symptoms: With the development of pituitary tumors, different degrees of headache, visual impairment and cranial nerve damage may occur. In some patients, due to the slow development of pituitary tumors, intracranial occlusion occurs after a long period of amenorrhea-galjuvant symptoms. Symptoms of positional lesions, some intrinsic patients can not appear clinical manifestations of pituitary tumors from beginning to end, in addition, some patients have obvious clinical manifestations of pituitary tumors before the onset of amenorrhea-galactorrhea symptoms.
5. Herbs caused by pituitary tumors - galactorrhea: generally no other abnormal secretion of pituitary hormones, blood growth hormone, thyroid hormone, antidiuretic hormone and ACTH are generally normal, so patients have no other clinical manifestations of endocrine dysfunction.
Examine
Examination of galactorrhea-menopausal syndrome
1. Prolactin determination: PRL determination is the most important diagnostic method. The serum PRL of normal women of childbearing age is 0.046~1.14nmol/L (1~25ng/ml), with an average of 0.36nmol/L (8ng/ml). PRL is generally <2.28nmol / L (50ng / ml), and quickly returned to normal after stopping the drug, PRL 4.55nmol / L (100ng / ml) more pituitary prolactinoma, the larger the tumor, the higher the PRL, the huge tumor hemorrhage The PRL may not rise.
2. Ovarian function test: serum FSH, LH, E2, P decreased, T can sometimes rise, vaginal exfoliated cells are mostly underlying cells, showing low levels of estrogen.
3. Thyroid function test: TSH may increase when T is low, and T3 and T4 decrease.
4. Liver and kidney function tests: combined with chronic liver and kidney disease, liver and kidney function may occur.
5. Pituitary prolactin function test: to assist in the diagnosis of pituitary prolactinoma.
(1) Thyrotropin-releasing hormone (TRH) test: normal women were injected with TRH 500 g intravenously. After 15 minutes, the blood PRL level was measured 1 to 2 times higher than that before injection. There was no significant increase in PRL in pituitary tumors.
(2) chlorpromazine test: chlorpromazine prevents norepinephrine absorption and transformation and dopamine function, promotes PRL secretion, normal women intramuscular injection of 25 ~ 50mg after 60 ~ 90min, blood PRL increased by 1 ~ 2 before injection Times, for 3 hours, pituitary tumors do not rise.
(3) Metoclopramide (Metoclopramide) test: This drug is a dopamine receptor antagonist, which promotes 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. The pituitary tumor does not rise.
(4) Levodopa test: This drug inhibits PRL secretion by decarboxylase to form DA. In normal women, after oral administration of 500 mg for 2 to 3 hours, PRL is significantly decreased, and pituitary tumors are not decreased.
(5) bromocriptine test: the drug is a dopamine receptor agonist, inhibiting the synthesis and release of PRL, normal women oral 2.5 ~ 5mg, 2 ~ 4h after PRL decreased 50%, lasting 20 ~ 30h, functional high prolactin Hemorrhage and prolactin adenoma decreased significantly.
6. Skull-sawed saddle image: Normal women's sphenial saddle diameter <17mm, depth <13mm, volume <1300mm, area <130mm, small pituitary tumor, bone often does not change.
7. CT and MRI examination: intracranial lesion localization and radiometry when blood PRL>2.73nmol/L (60ng/ml), help differential diagnosis of pituitary tumors and empty sella syndrome.
Diagnosis
Diagnosis and differential diagnosis of galactorrhea-menopausal syndrome
Diagnostic criteria
1. Ask in detail about the medical history, the cause of the disease and the history of menstruation, the history of breastfeeding, the history of medication and whether there are headaches or visual impairment.
2. Full physical examination pay attention to nutritional development, with or without obesity, hairy, chest condition, breast development and galactorrhea disease; check the nervous system and visual field to understand whether there is hypothalamic and pituitary disease; pay attention to whether the thyroid is swollen; Genital atrophy; ophthalmologic examination includes vision, visual field, intraocular pressure, and fundus examination to determine if there is a sign of tumor compression.
3. Laboratory examination of prolactin for ovarian function tests and imaging studies.
Differential diagnosis
It is distinguished from Sheen syndrome, which occurs in postpartum hemorrhage and has genital atrophic amenorrhea.
