galactorrhea-hyperprolactinemia
Introduction
Introduction Lactation is a physiological phenomenon in humans and even all mammals, while galactorrhea refers to pathological lactation in non-physiological conditions or during non-pregnancy lactation. Men have milk secretion almost all pathological conditions. Foreign countries report that some women of normal reproductive age are in non-pregnancy lactation, and can also squeeze a small amount of milk, which may be physiological. In general, women who are more likely to have lactation during non-pregnancy lactation or who have amenorrhea at the same time should be considered abnormal. Hyperprolactinemia refers to a higher level of serum prolactin (PRL) than normal (women 0.04-1.0 nmol/L, l-25 ng/ml; male 0.04-0.8 nmol/L, l-20 ng/ml) In terms of.
Cause
Cause
First, the cause classification
(1) Hypothalamic-pituitary lesions or dysfunction caused by dysfunction
Organic disease
(1) Hypothalamic infiltration or degenerative disease: due to a certain lesion, the hypothalamic-pituitary portal vein is blocked, thereby relieving the hypothalamic prolactin inhibitory factor (PIF) inhibition of pituitary PRL.
1 primary or secondary tumors: craniopharyngioma is the most common, followed by glioma, pineal tumor, ventricular tumor, aneurysm and so on.
2 infiltration: mainly granulomatous lesions, such as sarcoidosis, histiocytoma and so on.
3 degeneration: such as after encephalitis, post-cranial meningitis, embolism in the hypothalamic area.
(2) pituitary lesions
1 prolactinoma or primary prolactin cell proliferation: excessive secretion of prolactin can cause milk spill, the most common.
2 pituitary auxotrophs (giant disease and / or acromegaly): its milk spill can be caused by growth hormone (GH) with milk, or at the same time increased PRL release.
3 pituitary ACTH tumor (Cushing's disease) in addition to the secretion of a large number of ACTH caused by hypercortisolism, can also secrete too much PRL and cause milk spill. Nelson syndrome may be due to the enlargement of pituitary tumors to compress the pituitary stalk, blocking the hypothalamic prolactin inhibitor to reach the anterior pituitary and causing an increase in PRL secretion.
4 pituitary mixed cell tumor: its composition with GH tumor. There are more ACTH tumors and PRL tumors. Two or more hormone mixed tumors such as GH+PRL, GH+ACTH, GH+PRL+TSH.
5 vacuolar sella syndrome: due to pituitary compression, adhesion and other reasons, a small number of patients may have amenorrhea, such as amenorrhea, milk spill and other endocrine symptoms.
(3) pituitary stalk damage: traumatic or surgical cutting of the pituitary stalk.
2. Functionality
(1) Chiari-Frommel syndrome: related to pregnancy, refers to the onset of postpartum with amenorrhea.
(2) Chest and breast disorders: found in irritating nipples and nipple areas, such as sucking nipples, chronic mastitis, banded sores, thoracic chest wall and heart surgery, breast tumors and other chest wall lesions, stimulating nipples and peripheral nerves, through The spinal cord and brainstem affect the hypothalamic function, thereby relieving its inhibition of pituitary PRL and causing galactorrhea.
(3) cranial and thoracic spinal cord lesions or damage: such as spinal cord spasm, syringomyelia also occasionally galactorrhea.
(4) drugs
1 Estrogen: Oral contraceptives may stimulate hyperplasia of PRL cells and increased PRL secretion.
2 drugs that inhibit the secretion of dopamine in the hypothalamus or affect its effects and cause excessive secretion of pituitary PRL: such as phenothiazines (chlorpromazine, butyrylazine, chloralazine, perphenazine); thioxanthens or thioindigos (chloropyrrole); phenylbutanone (Hopperidone) biphenyl butyl piperidine (); and ketoprofen succinate, morpholinone; catecholamine depleting agent (methyldopa) , blood () blood; procainamide derivatives (metoclopramide, sulpiride); H2 - receptor blockers (such as cimetidine); opiates (morphine, vaginal pain).
(5) Mental factors: stress, false pregnancy, etc., rare.
(two) thyroid disease
Primary hypothyroidism
Probably due to decreased secretion of thyroid hormone, and increased secretion of TRH in the hypothalamus, stimulated the secretion of PRL in the pituitary.
2. Hyperthyroidism
It is very rare for patients with this disease to have galactorrhea. Can be seen in GraVe disease, multi-nodular goiter, and drug-induced hyperthyroidism. Pituitary tumors should be carefully excluded during diagnosis, especially in pituitary mixed adenomas. The cause of milk spill is unknown. The PRL in the blood of the patient is generally normal. Although it is not caused by abnormal secretion of PRL, thyroid hormone is not a hormone necessary for galactorrhea, but it may affect the production of milk, which may be related to various endocrine and metabolic changes during hyperthyroidism. For example, elevated levels of sex hormone-binding globulin or changes in estrogen metabolism caused by hyperthyroidism may cause changes in free estrogen levels to cause galactorrhea.
(c) Adrenal disease
1. Primary adrenal insufficiency is occasionally edema.
2. Adrenal cortical tumor
(4) Estrogen-secreting tumors (derived from the ovary or adrenal cortex) with galactorrhea. Estrogen levels in patients with polycystic ovary syndrome are generally normal or relatively elevated due to increased secretion of PRL by estrogen. The relatively stable level of estrogen can stimulate the proliferation and proliferation of PRL cells and the increase of PRL synthesis through synergistic action.
(5) Heterologous PRL secretion syndrome
It is found in bronchial lung cancer (undifferentiated type), kidney cancer, and can produce a PRL-like substance or a substance that inhibits the hypothalamic prolactin inhibitor.
(6) Speciality
Generally seen in women with galactorrhea, normal menstruation, genital not shrinking, clinically unclear reasons.
In short, the above various reasons cause pathological lactation through different ways, except for some etiology and pathogenesis, most of them have hyperprolactinemia. Since too much prolactin can directly inhibit the secretion of pituitary gonadotropin, on the other hand, it can also inhibit the action of gonadotropin on the ovary, so the patient's PRL is elevated. The reduction of gonadotropin and the lack of estrogen secretion, in addition to the performance of milk spill, some patients also have amenorrhea, yang, infertility and genital atrophy.
Examine
an examination
Related inspection
Breast examination breast examination
(1) Detailed medical history
The most important thing is whether to apply the above-mentioned history of drugs, as well as the period of use, the time of suspension, etc., whether there are diseases related to these drugs, hypertension, ulcer disease, mental disorders, insomnia, hormone therapy, history of menstruation, history of breastfeeding and Its relationship with the milk spill.
(two) clinical characteristics
1. Milk spill and menstrual disorders syndrome
Patients can consciously or unconsciously galactorrhea, milk can be more or less, milky white, lactose qualitative positive, can occur in unilateral or bilateral breasts, but also can alternate breast milk. Normal breast development can also increase or shrink. Men with galactorrhea, with more breast enlargement. Most have secondary amenorrhea, mild menstruation is normal, but the amount of menstruation is reduced or no ovulation, often with infertility.
2. Pituitary tumor syndrome
Among them, prolactin microadenomas are more common, and female patients only have galactorrhea and menstrual disorders in the early stage. Men are characterized by loss of libido and yang. As the tumor grows, headache, vision loss, and visual field defects may occur. Acromegaly or hypercortisolism is still seen.
3. galactorrhea amenorrhea syndrome
Most are caused by pituitary microadenomas or pituitary tumors. There are three types.
(1) Chiari-Formmel syndrome: more than postpartum continuous amenorrhea or postpartum tidal 1 or 2 times followed by continued amenorrhea. At the same time, after continuous lactation or continuous breastfeeding for several weeks, galactorrhea occurred; libido decreased, genital atrophy; blood PRL increased, FSH and estrogen decreased; X-ray examination of the saddle was not large. A few years later, a considerable number of patients developed pituitary tumors.
(2) Del-Castillo syndrome: non-partum onset, not related to pregnancy and lactation. The clinical manifestations are similar to those of Chiari-Formmel syndrome, and the sella does not expand. No pituitary tumors. However, a considerable number of patients have found pituitary tumors after many years.
(3) Forbes-Albright syndrome: prenatal and postpartum can start disease, in addition to persistent galactorrhea, amenorrhea and genital atrophy, some patients may have obesity, hairy or mild acromegaly appearance. Blood PRL increased and was not inhibited by L-dopa, FSH, LH and estrogen levels were reduced, and X-ray showed enlargement of the sella. About half of the patients have pituitary tumors.
(three) endocrine examination
1. Determination of plasma PRL basic value and dynamic function test
It is the main basis for the diagnosis of prolactinoma. If the PRL basal value exceeds normal but <2. nmol/L (50 ng/ml), it is likely to be caused by drugs; >4.0 nmol/L (100 ng/ml) may have prolactinoma; for example, >8.0 nmol/L ( 200 ng / ml) is helpful for the diagnosis of pituitary prolactinoma. Excitation tests such as TRH, chlorpromazine and metoclopramide or L-Dopa or bromocriptine inhibition test, or L-DOpa and Carbidopa combined test may be used to facilitate the diagnosis of the cause.
2. Other endocrine examinations
(1) Determination of thyroid function: T3, T4, TSH.
(2) Determination of gonadotropin (TSH, LH) and estrogen and androgen levels.
(3) GH determination and its dynamic function test: In addition to measuring the basic value of GH, patients with acromegaly do glucose or bromocriptine inhibition test if necessary.
(4) Determination of adrenal cortical function: with hypercortisolism, blood, urine free cortisol, 24h urine 17-0HCS, 17-KS level and dexamethasone inhibition test.
(5) related tests for heterologous hormone secretion syndrome: such as undifferentiated lung cancer, kidney cancer and the like.
(4) X-ray examination
Head plain film, tomography (such as thin layered photography of the saddle), especially CT, MRI examination, is of great value for the early detection of pituitary adenoma.
Diagnosis
Differential diagnosis
The diagnosis should be differentiated from the following symptoms:
1. Amenorrhea - galactorrheid - infertility triad: The typical symptom of prolactinoma is amenorrhea - galactorrheid - infertility triad. Prolactinoma refers to a tumor in which the pituitary gland secretes PRL, and the incidence of pituitary functional (secreted) tumors is the highest.
2. Postpartum milk self-existing means that the postpartum milk continuously flows out without sucking by the baby, also known as "leaking milk", "postpartum milk spill" or "milk self-surge". If galactorrhea occurs during pregnancy, it is "milk weeping." If the lactating mother is in good health, strong in constitution and strong in nutrition, it is generally considered normal because the breast is full and the breast is full and naturally flows out. There is also a milk out of the disease caused by the disease, the disease occurs in the postpartum, may be related to breast gland function or structural abnormalities, such as galactorrhea unrelated to pregnancy can be related to endocrine disorders.
