Reviews in GYNAECOLOGICAL PRACTICE
ELSEVIER
Reviews in Gynaecological
Practice 3 (2003) 180-187 www.elsevier.comllocate/rigp
Prolactinomas in infertility Kulvinder Kaura,*, Mandeep Singh b,I, S.P.S. Virka,2 a Rotunda Virk-Center for Human Reproduction. 360. Guru Teg Bahadur Nagar. lalandhar /44003. Punjab. India b Gundeep Hospital. 8. Guru Teg Bahadur Nagar Extension, lalandhar 144003, Punjab, India
I
Received 24 April 2003; accepted 9 June 2003
Abstract Hyperprolactinaemia is the most common disorder of the hypothaIamo-pituitary axis. Prolactinomas are the most common honnonesecreting pituitary tumours. Rarely life-threatening, they cause symptoms primarily as a result of hyperprolactinaemia which results in alteration in reproductive/sexual function, but may also cause symptoms owing to mass effects. A prolactinoma should be suspected if the serum prolactin is 2:100ng/ml. The goals of treatment are to normalise prolactin levels, restore gonadal function and reduce the effects of chronic hyperprolactinaemia. . Dopamine agonists are the first choice of treatment for the majority of patients. Transsphenoidal surgery should rarely be considered for patients desiring fertility and is reserved for patients intolerant or resistant to dopamine agonists or when hyperprolactinaemia is caused by non-prolactin-secreting pituitary tumours compressing the pituitary stalk. Cabergoline has been shown to be more effective and better tolerated than bromocriptine. However, there are more data on the safety of the latter drug during pregnancy and bromocriptine therefore remains the treatment of choice in hyperprolactinaemic women wishing to conceive. @ 2003 Elsevier B.Y.All rights reserved. Keywords: Hyperprolactinaemia;
Prolactinoma;
Dopamine agonists; Bromocriptine;
1. Introduction Prolactin-secreting adenomas are the most common hormone-secreting (functional) pituitary tumours in both autopsy and surgical series [I]. They are generally classif!ed
clinicallyby size: microadenomas« 10mm in diameter) and macroadenomas (> I0 mm in diameter with or without extrasellar extension). Prolactinomas occur more frequently in women than in men and differ not only in size, but also in clinical presentation, invasive growth and secretory activity. The vast majority (95%) of prolactinomas in women are microadenomas, which present with the clinical manifestations of hyperprolactinaemia, and rarely lead to hypopituitarism or neurologic dysfunction. In contrast, men with prolactinomas often present, because of symptoms due to the size of the tumour rather than impotence, loss of libido or infertility.
Cabergoline;
Pregnancy
Radiological investigation demonstrates a macroadenoma in over 90% of cases in men [2]. Macroadenomas may cause with local mass effects-hypopituitarism, headache, visual field defects, or they may invade local structures to cause ophthalmoplegia and neurologic dysfunction (e.g. seizures or hemiparesis). 1.1. Pituitary incidentaloma The percentage of pituitary glands found to contain unsuspected adenomas, all microadenomas, ranged from 1.7 to 27% in autopsy series [1]. From postmortem studies, risk of progression of microadenomas to macroadenomas is about 3% and that from other carefully followed-up patients is 6-9%, i.e. 93-97% of microadenomas remain small.
2. Physiologyof prolactin
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1471-7697/$ - see front matter @ 2003 Elsevier B.V. All rights reserved. doi: 10.1016/5 1471-7697(03)00060-1
I
Prolactin is a 199-amino acid single-chain polypeptide encoded by a single gene on the short arm of chromosome 6 and has a structural similarity with growth hormone and human placental lactogen. It circulates in three different sizes: the small monomer form, the big or dimer form, and the big big or polymeric form. The heterogeneity of molecule is also
