Hyperprolactinaemia (also spelled hyperprolactinemia) is a condition characterized by abnormally high levels of prolactin in the blood. In women, normal prolactin levels average to about 13 ng/mL, while in men, they average 5 ng/mL. The upper normal limit of serum prolactin is typically between 15 and 25 ng/mL for both men and women. Hyperprolactinemia, characterized by abnormally high levels of prolactin, may cause galactorrhea (production and spontaneous flow of breast milk), infertility, and menstrual disruptions in women. In men, it can lead to hypogonadism, infertility and erectile dysfunction.
Prolactin is crucial for milk production during pregnancy and lactation. Together with estrogen, progesterone, insulin-like growth factor-1 (IGF-1), and hormones from the placenta, prolactin stimulates the proliferation of breast alveolar elements during pregnancy. However, lactation is inhibited during pregnancy due to elevated estrogen levels. Typical antipsychotics have been shown to induce significant, dose-dependent increases in prolactin levels up to 10-fold the normal limit. Atypical antipsychotics vary in their ability to elevate prolactin levels; however, medications in this class, such as risperidone and paliperidone, carry the highest potential to induce hyperprolactinemia in a dose-dependent manner similar to typical antipsychotics.
Signs and symptoms
In women, high blood levels of prolactin are typically associated with hypoestrogenism, anovulatory infertility, and changes in menstruation. Menstruation disturbances commonly manifests as amenorrhea or oligomenorrhea. While mild hyperprolactinemia may not always result in menstrual disorders, it is uncommon for women to have normal menstrual cycles if their serum prolactin levels exceed 180 ng/ml (3,600 mU/L). In such cases, irregular menstrual flow may result in abnormally heavy and prolonged bleeding (menorrhagia). This phenomenon is likely due to galactorrhea requiring adequate levels of progesterone or estrogen to prepare the breast tissue. Additionally, some women may also experience loss of libido and breast pain, particularly when prolactin levels rise initially, as the hormone promotes tissue changes in the breast. Unlike women, men do not experience reliable indicators of elevated prolactin such as menstrual changes, to prompt immediate medical consultation.
Men often present late in the course of hyperprolactinemia, typically with symptoms related to the expansion of their pituitary tumor, such as headaches, visual defects, and external ophthalmoplegia, or symptoms from secondary adrenal or thyroid failure. Unlike women, who most commonly have microprolactinomas, men usually present with macroprolactinomas, and their serum prolactin levels are generally much higher than those observed in women.
Long-term hyperprolactinaemia can lead to detrimental changes in bone metabolism as a result of hypoestrogenism and hypoandrogenism. Studies have shown that chronically elevated prolactin levels lead to increased bone resorption and suppress bone formation, resulting in reduced bone density, increased risk of fractures, and increased risk of osteoporosis. In men, the chronic presence of hyperprolactinemia can lead to hypogonadism and osteolysis. The prevalence of bone impairment is significantly higher in men with prolactinomas compared to women. Impaired bone mineral density (BMD) serves as an "end organ" marker, reflecting the full extent of the disease. It could potentially become a surrogate marker for the severity of long-term hyperprolactinemia and associated hypogonadism.
Causes
Prolactin secretion is regulated by both stimulatory and inhibitory mechanisms.
Hyperprolactinemia inhibits the secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which in turn inhibits the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland and results in diminished gonadal sex hormone production (termed hypogonadism). This is the cause of many of the symptoms described below.
In many people, elevated prolactin levels remain unexplained and may represent a form of hypothalamic–pituitary–adrenal axis dysregulation.
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! Causes of hyperprolactinemia During pregnancy, prolactin increases can range up to 600 ng/mL, depending on estrogen and progesterone concentrations. After delivery, progesterone concentrations decrease, and prolactin levels drop. Only during nipple stimulation will prolactin levels rise, allowing for milk production. At 6 weeks post-birth (postpartum), estradiol concentrations decrease, and prolactin concentrations return to normal even during breastfeeding. Fluctuations in prolactin levels during menstrual cycles and menopause are inconclusive.
Stress-related factors include physical exercise, hypoglycemia, myocardial infarction, and surgery. While aerobic and anaerobic activity increases prolactin, anaerobic activity has a greater effect. Prolactin serum concentrations increase during nocturnal sleep, and increase transiently during daytime naps. After waking, prolactin levels return to daytime levels within 60–90 minutes.
Medications
Prolactin secretion in the pituitary lactotroph cells is normally suppressed by the brain chemical dopamine, which binds to dopamine receptors. Drugs that block the effects of dopamine at the pituitary or deplete dopamine stores in the brain may cause the pituitary to secrete excess prolactin without an inhibitory effect. These drugs include the typical antipsychotics: phenothiazines such as chlorpromazine, and butyrophenones such as haloperidol; atypical antipsychotics such as risperidone and paliperidone; gastroprokinetic drugs used to treat gastro-esophageal reflux and medication-induced nausea (such as that from chemotherapy): metoclopramide and domperidone; less often, alpha-methyldopa and reserpine, used to control hypertension; and TRH. Aripiprazole, while an atypical antipsychotic, lowers prolactin levels as it is contains both agonistic and antagonistic dopamine-receptor activity. The melatonin receptor agonist ramelteon also increases the risk of hyperprolactinemia, however, the mechanism is unclear.
Specific diseases
A common cause for hyperprolactinemia is prolactinomas and other tumors arising near the pituitary. These adjacent tumors, such as those that cause acromegaly, can physically compress the pituitary stalk and block the flow of dopamine from the hypothalamus to the pituitary gland, causing prolactin levels to increase. Other causes include chronic kidney failure, hypothyroidism, liver cirrhosis, bronchogenic carcinoma and sarcoidosis. Hyperprolactinemia develops in one-third of individuals with chronic kidney disease due to impaired renal clearance and regulation. In men, hyperprolactinemia leads to hypoactive sexual desire and, occasionally, erectile dysfunction. However, the link between erectile dysfunction and prolactin levels is not conclusive. When prolactin levels return to normal in these individuals, sexual desire fully recovers; however, erectile dysfunction only partially recovers.
Nonpuerperal mastitis may induce transient hyperprolactinemia (neurogenic hyperprolactinemia) of about three weeks' duration; conversely, hyperprolactinemia may contribute to nonpuerperal mastitis. Some inflammatory conditions, such as rheumatoid arthritis and systemic lupus erythematosus, are also linked to higher prolactin levels in certain regions.
Apart from diagnosing hyperprolactinemia and hypopituitarism, prolactin levels are often checked by physicians in those who have had a seizure, when there is a need to differentiate between epileptic seizure or a non-epileptic seizure. Shortly after epileptic seizures, prolactin levels often rise, whereas they are normal in non-epileptic seizures.
Diagnosis
An appropriate diagnosis of hyperprolactinemia starts with conducting a complete clinical history before performing any treatment. Physiological causes, systemic disorders, and the use of certain drugs must be ruled out before the condition is diagnosed. Screening is indicated for those who are asymptomatic and those with elevated prolactin without an associated cause.
The most common causes of hyperprolactinemia are prolactinomas, drug-induced hyperprolactinemia, and macroprolactinemia. Individuals with hyperprolactinemia may present with symptoms including galactorrhea, hypogonadism effects, and/or infertility. The magnitude that prolactin is elevated can be used as an indicator of the etiology of the hyperprolactinemia diagnosis. Prolactin levels over 250 ng/mL may suggest prolactinoma. Prolactin levels less than 100 ng/mL may suggest drug-induced hyperprolactinemia, macroprolactinemia, nonfunctioning pituitary adenomas, or systemic disorders.
Elevated prolactin blood levels are typically assessed in women with unexplained breast milk secretion (galactorrhea) or irregular menses or infertility, and in men with impaired sexual function and milk secretion. If high prolactin levels are present, all known conditions and medications which raises prolactin secretion must be assessed and excluded for diagnosis. After ruling out other causes and prolactin levels remain high, TSH levels are assessed. While a plain X-ray of the bones surrounding the pituitary may reveal the presence of a large macroadenoma, small microadenomas will not be apparent. Magnetic resonance imaging (MRI) is the most sensitive test for detecting pituitary tumors and determining their size. In addition to assessing the size of the pituitary tumor, physicians also look for damage to surrounding tissues, and perform tests to assess whether production of other pituitary hormones are normal. Depending on the size of the tumor, physicians may request an eye exam that includes the measurement of visual fields. In diagnosing hyperprolactinaemia in men, some physical signs may indicate the onset of the condition. Increased prolactin can affect the inhibition of GnRH secretion, which is responsible for libido, and the release of FSH (Follicle-stimulating hormone), LH (Luteinizing hormone), and testosterone. FSH in men is responsible to stimulate sperm production and LH is responsible for the stimulation of testosterone; with the inhibition of GnRH, FSH, and LH, physical signs that show in men include reduced sex drive and infertility, these symptoms suggests the onset of hyperprolactinaemia.
However, a high measurement of prolactin may also result from the presence of macroprolactin, otherwise known as 'big prolactin' or 'big-big prolactin', in the serum. Macroprolactin occurs when prolactin polymerizes together and can bind with IgG to form complexes. Antigen tests such as the pregnancy test shows positive line via the formation of a sandwich immune complex that allows the positive line to be visible, in the occurrence of Hook Effect, large amounts of analyte exists in the solution which saturates the antibodies, preventing normal binding and formation of the sandwich immune complex therefore showing a weak positive line. In the case of diagnosing hyperprolactinaemia, a weak positive line can often lead to a false negative result and increase the risk of misdiagnosis of the condition or a potential pituitary adenomas. If Hook Effect is suspected in the patient diagnosis, serial dilution of the analyte until the concentration of prolactin falls within the assay's analytical measurements is suggested. Ruling out the possibilities of false negatives is important to ensure patients receive necessary care for their conditions. On the other hand, the treatment of hyperprolactinemia in children and adolescents with antipsychotic medications has been studied to provide guidelines, as these medications may adversely affect child growth and development. Results have shown that aripiprazole significantly decreases prolactin levels compared to other medications such as olanzapine and risperidone, which result in increased prolactin levels. Pharmacologic hyperprolactinemia, the concerning drug can be switched to another treatment or discontinued entirely. No treatment is required in asymptomatic macroprolactin and instead, serial prolactin measurements and pituitary imaging are monitored in regular follow-up appointments. quinagolide and bromocriptine (often preferred when pregnancy is possible), are the treatment of choice used to decrease prolactin levels and tumor size upon the presence of microadenomas or macroadenomas. A systematic review and meta-analysis has shown that cabergoline and quinagolide are more effective in the treatment of hyperprolactinemia compared to bromocriptine, this is because evidence had suggested fewer side effects, rapid titration and offers better dosing interval in medication like quinagolide compared to bromocriptine. Similar studies have been conducted regarding the safety and efficacy of dopamine agonists. According to SUCRA (Surface Under the Cumulative Ranking) and SMAA (Stochastic Multicriteria Acceptability Analysis), quinagolide was found to be the best treatment for women since it can help reduce menstrual irregularities, in addition bromocriptine was shown to be more effective in the treatment for galactorrhea (breast milk production unrelated to pregnancy), and cabergoline was the safest medication as it did not show any alarming side effects. Other dopamine agonists that have been used less commonly to suppress prolactin include dihydroergocryptine, ergoloid, lisuride, metergoline, pergolide, and terguride. If the prolactinoma does not initially respond to dopamine agonist therapy, such that prolactin levels are still high or the tumor is not shrinking as expected, the dose of the dopamine agonist can be increased in a stepwise fashion to the maximum tolerated dose.
Surgical therapy can be considered if pharmacologic options have been exhausted.
See also
- Hypothalamic–pituitary–prolactin axis
- Hypopituitarism