AMENORRHOEA

GALACTORRHEA,
HYPERPROLACTINEMIA,
ADENOMA HYPOPHYSIS

Dr. Muhammad Yusuf., SpOG (K)

Sub-Bagian Fertilitas Endokrinologi Reproduksi
RSUD Arifin Achmad Pekanbaru
GALACTORRHEA
Inappropriate lactation
Persistence of lactation for more than one year

after normal delivery and cessation of breast

feeding
Milk production that occurrence in the absence of
pregnancy.

Inappropriate lactation may be an important clue to the presence of pituitary-

hypothalamic disease, especially if accompanied by amenorrhea
 NO FEATURES OF ANDROGEN EXCESS
PRESENT
Physiological, e.g. pregnancy, lactation, menopause

ETIOLOGIES
Iatrogenic, OF SECUNDARY
e.g. depot medroxyprogesterone acetate contraceptive
injection, radiotherapy, chemotherapy
AMENORRHOEA
Systemic disease, e.g. chronic illness, hypo- or hyperthyroidism
Uterine causes, e.g. cervical stenosis, Asherman's syndrome (intra-
uterine adhesions)
Ovarian causes, e.g. premature ovarian failure, resistant ovary syndrome
Hypothalamic causes, e.g. weight loss, exercise, psychological distress,
chronic illness, idiopathic
Pituitary causes, e.g. hyperprolactinaemia, hypopituitarism,
Sheehan's syndrome
Causes of hypothalamic/pituitary damage, e.g. tumours, cranial
irradiation, head injuries, sarcoidosis, tuberculosis
THE PITUITARY GLAND

Located at the
base of the
skull
Anterior and
Posterior lobes
Portal
connection
from the
hypothalamus
Hypothalamus
hormones
 THE TARGET ORGANS OF PITUITARY HORMONS

The adult pituitary measures 6 mm in diameter and weights about 0.6 gr. At least
seven hormones are synthesized and released by the anterior lobe of the pititary.
 HYPOTHALAMIC

RELEASING
INHIBITING
FACTORS
FACTORS

Gonadotropin (GnRH)
Prolactin (PRH) Somatostatin
Thyrotropin (TRH) Prolactin Inhibiting Factor
Corticotropin (CRH) (PIF)
Growth-Hormone (GHRH)
LUTEOTROPIC HORMONE
Proteinaeous gonadotropic hormone
produced in the pars distalis of the anterior
pituitary.
From the hypothalamus there are two

different releasing hormones produced that

affect the release or non-release of LTH.
These are PRH and PIH.
LTH CONTINUED
Prolactin releasing hormone (PRH) from the
hypothalamus stimulates a release of
prolactin or LTH which acts on the corpus
luteum to stimulate progesterone production
and release.
As LTH rises in the blood and hits its preset
threshold, PIH or prolactin inhibiting
hormone is released from the hypothalamus.
LTH CONTINUED
As long as progesterone remains in the blood
because of LH maintenance of the CL and
LTH stimulation of the CL the levels of
progesterone will be maintained at a
constant level.
As a side effect, LTH inhibits the release of
GnRH by the hypothalamus. Remember,
LTH high, no GnRH, no FSH, no cycle.
 Prolactine is a hormone
synthesized and secreted by
specific cells (lactotrophic
cells) of the anterior lobe of
pituitary gland.

The secretion of prolactine is

under the influence of the
catecholamic dopamine (PIF)
released into the hypophyseal
portal blood system from
hypothalamic neuron

The circulatting prolactine is

thought to control its own
secretion via a feed back
mechanism
 DOPAMINE (DA)
Dopamine is a neurotransmitter and, like all
neurotransmitter, is synthesized, stored by
and released from a nerve cell or neuron, the
smallest functional unit of the nervous system.
Dopamine is carried via the hypophyseal
circulation to the anterior pituitary, where it
binds to the dopamine receptors on the
lactotrophic cells and prevent the release of
prolactine.
 The loss of hypothalamic
control causes excessive
prolactin release, resulting in
various conditions classified
as prolactin-related disorders

The pathological actions of

raised prolactin levels :
1. Inhibition of GnRH
secretion by the hypothalamic
neuron.
2 and 3, Inhibition of gonadal
receptors for FSH and LH.
4. Unphysiological
stimulation of milk secretion.
PROLACTINOMAS
Most common functional pituitary tumor
10% are lactotroph and somatotroph such as GH

producing
Presents with amenorrhea and infertility

Prolactinomas lose TRH response

Microadenomas <10mm on MRI

Macroadenomas >10mm
 HYPERPROLACTINAEMIA
A prolactinoma is the commonest cause of
hyperprolactinaemia (60% of cases).
Other causes include non-functioning pituitary
adenoma (disrupting the inhibitory influence of dopamine
on prolactin secretion);
dopaminergic antagonist drugs (e.g. phenothiazines,
haloperidol, clozapine, metoclopramide, domperidone,
methyldopa, cimetidine); primary hypothyroidism
(thyrotrophin-releasing hormone stimulates the secretion
of prolactin), or it may be idiopathic.
Prolactin acts directly on the hypothalamus to
reduce the amplitude and frequency of pulses of
gonadotrophin-releasing hormone.
CAUSES OF
HYPERPROLACTINEMIA
CAUSES OF
HYPERPROLACTINEMIA
Pathological causes
Causes of Hyperprolactinemia
 Premenopausal women
Marked prolactin excess (> 100 g/L
[normally < 25 g/L]) is commonly
associated with hypogonadism,
galactorrhea and amenorrhea
Moderate prolactin excess (5175 g/L)
is associated with oligomenorrhea
Mild prolactin excess (3150 g/L) is
associated with short luteal phase,
decreased libido and infertility
 Premenopausal women

Increased body weight may be

associated with prolactin-secreting
pituitary tumour

Osteopenia is present mainly in people

with associated hypogonadism

Degree of bone loss is related to duration

and severity of hypogonadism
Mass effects (macroadenomas)
DIAGNOSI
S
Hiperprolaktinem
ia
Efek massa
Hipogonadism tumor
e
Oligomenorea,
(makroadenoma
amenore Headache )
Subfertil Hilang visus
Galaktorea Neuropati kranial
Penurunan libido Kejang
Osteopenia Rhinorea cairan
serebrospinal
APPROACH TO DIAGNOSIS OF
HYPERPROLACTINEMIA
Prolactine level

Macropro Repeat Rule out secondary

lactinemia measurement causes

Pathological Correct underline

hyperprolactinemia cause: Replace
thyroid hormone
MRI Pituitary etc.

Normal Micro lesion Macro lesion

Asymptomatic Symptomatic

Follow up prolactin
measurement
Treatment
TERIMA KASIH

Thanks Young
Docters