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Hyperprolactinemia
Macro-prolactinoma:
• Adenoma size>1cm
• if prolactin levels >6000 mU/l mostly due to macroprolacttinoma.
Diagnosis: 1. Hormone Assay (often levels are >1000mU/l in adenomas), 2.MRI pituitary- definitive
Treatment of prolactinoma
1. Treatment of both micro and macro-adenomas can be initiated with dopamine agonists: Cabegoline
superior to Bromocriptine mcq
2. If fails, treat trans-sphenoidal surgery.- Definitive treatment mcq
3. Radiotherapy also an option
Pituitary tumors with compression symptom- Always surgery is the choice mcq
In some idividual, the majority of the prolactin is in macro form. So, the prolactin assays in these
ividuals shows very high prolactin levels even though these individual don’t develop any symptom
because macro-prolactins are biologically inactive.
Important point is: If you see an mcq which says patient is asymptomatic, but prolactin levels are
high, then, the answer is Macro-prolactinemia. mcq. No treatment needed for Macro-prolactinemia
3. Stalk compression
Here is the answer to the question in the previous page:
80% of pituitary adenomas are non functional ( don’t produce any hormone).mcq
However, this non functional adenomas sometimes can compress the stalk when it enlarges and cut
the dopamine access to the pituitary. So, no more dopamine inhibition for prolactin secretion. This
will eventually leads to hyperprolactinemia.
As you all know, Pitutary tumors can compress the Optic chiasma and can produce bitemporal-
hemianopia (peripheral vision loss). mcq
Those who enjoy medicine, read the following. Others start the MCQs.
If you can understand following talk about dopamine, you can understand the actions and side effects of
many drugs without memorizing.
There are 4 main places in the brain where dopamine exert it’s effects
1. Hypothalamus-Pituitary axis – Dopamine inhibits prolactin
2. Meso-limbic system – Increase dopamine produces psychotic symptoms (hallucinations..)
3. Vomiting center in the medulla – Dopamine induces vomiting
4. Basal Ganglia ( Substantia Nigra) – Lack of dopamine in basal ganglia produces Parkinson disease)
Now we work out the effects and side effects of the drugs which have effect on dopamine system
In hypothalamo-pituitary axis
Bromcriptine / cabegoline are dopamine agonist used as first line treatment against prolactinoma
• So, both these drugs can also be used in parkinson disease too.
• However, dopamine agonist effect in the mesolimbic system produces psychotic symptoms
• Increase dopamine induces vomiting centre induces vomiting
In Meso-limbic system
Anti-psychotics are dopamine antagonists act in mesolimbic system against psychosis and schizophrenia.
• Due to this anti-dopaminergic actions of Anti psycotics. hypothalmo-pituitary axis produces more
prolactin and galactorrhea
• Due to this anti-dopaminergic in the basal ganglia it produces drug induce parkinsonism.
Vomiting centre
Anti-emetics such as metoclopramide and domperidone antagonize the dopamine in the vomiting centre and
produces anti-emesis
• Both these drugs can be used to produce increased lactation to those newly delivered mothers who don’t
produce adequate breast milk-specially soon after delivery.
• Metochlopramide can cause movement related disorder like dystonic reactions-MCQ
Basal-ganglia
Drugs used in parkinson disease exerts their dopamine agonist action in substantia nigra.
• However, these drugs can even act on meso-limbic system and can produce hallucinations.
Here are the mcqs. Good luck!
Answers
1 E. 4 Hormones increases the blood sugar Must know in plab
1. Glucagon
2. Corticosteroids
3. Adrenaline
4. Growth hormone
Don’t worry, we will learn everything about GH when we do the pituitary hormones part.
2 C
3 A.
It is the commonest cause for primary hyperprolactinemia
4 A. cabergoline and bromocriptine inhibit prolactin secretion
5 D
6 E
7 E
8 E
9 D. If prolactin levels are between 1000-6000mU/l, most likely cause is micro-prolactinoma
10 C. Just want to introduce some pituitary conditions before we go to the topic.
11 B
12 E
13 B
14 A
15 C
16 D.
17 B
18 c