Still> 100 ng/ml (irrespective of menstrual cyclicity/galactorrhea). > 100"911'" ... Normal. Non-secretory. CT Scan. Tumor and increased prolactin because of Stalk compresion ... with serum prolactin levels (>24ng/ml) at Rotunda. Virk Center for ...
How do we Treat Prolactinomas in Infertility?
89
Serum Prolactin > 100 ng/ml
~
Repeat fasting serum prolactin Rule out history of renal failure and drugs causing hyperprolactinemia and hypothyroidism
~ Still>
100 ng/ml (irrespective
of menstrual cyclicity/galactorrhea)
> 1000 ng/ml (usually invasive macroprolactinoma
> 250 ng/ml but < 1000 ng/ml usually microprolactinoma (noninvasive)
> 100"911'"
~
< 250"Iml
J ~
CT scan/MRI
CT scan/MRI
~
Usually due to cavernuous sinus invasion
Locally invasive Microadenoma (Microprolactinoma)
Medical treatment (Dopamine agonist)
MacroMicroprolactinoma Macroadenoma Normal Non-secretory CT Scan prolactinoma (occasionally) Tumor and increased prolactin because of Stalk Medical treatment compresion (Dopamine agonist)
i
Refer for surgical treatment No cause Rule out autoantibody & (Idiopathic high molecular wt. hyperprolactinemia) Prolactin
~
No treatment / Medical treatment (As per infertility requirement) Fig. 10.4: Management
~
Medical treatment (Dopamine agonist)
of a case of hyperprolactinemia
with serum prolactin levels (>24 ng/ml) at Rotunda Virk Center for Human Reproduction in the last 2 years. Of these patients, 24 presented with secondary amenorrhea; 12of whom, also had galactorrhea. Fiftyeight patients presented with irregular cycles, 8 of whom also had galactorrhea, and 196 patients had normal cycles with galactorrhea in 16. There were a total of 39 patients with serum prolactin levels (>100 ng/ml). The detailed analysis is shown in Table 10.2. This study highlights that patients with prolactinomas may not necessarily present with cycle irregularity and I or galactorrhea.
Autoantibodies
~ ~
> 2000 ng/ml
approx. 1000 ng/ml
N
and high molecular wt. prolactin (Occasionally)
i
No treatment / Medical treatrment (As per infertility requirement)
Surgical results poor -Hence long-term control with Dopamine agonists
In Macroprolactinomas with visual field defects Visual impairment improves rapidly with Dopamine agonist therapt. (But maximum effect takes several months)
(> 100 ng/ml) with infertility (flow. diagram)
PATHOGENESIS OF PROLACTINOMAS
Although an early theory suggested that prolactinomas arise because of underlying hypothalamic dysregulation, the current consensus is that pro lactinomas arise from the clonal proliferation of a single mutated cell.12 Many studies have attempted to determine the precise mutation that could cause prolactinomas. Rearrangement or amplification of oncogenes, such as mye, jos, jun RAS and gsp, has not been associated with any irregularityP Prolactinomas occur in approximately 20percent of the patients with multiple
