yperprolactinaemia & Amenorrhoea, some points are left,so today i’m going to start from that, Hyperprolactinaemia causes secondary amenorrhoea in about 30% of women. There is anovulation & hypogonadotrophic hypogonadism. (I) Pituitary Adenoma (Prolactinoma):-Hyperprolactinaemia is commonly due to pituitary adenomas (microadenoma or macroadenoma). There are other various causes of hyperprolactinaemia. Causes of Hyperprolactinaemia;
[A] Physiological:-(1) Stress & exercise(raised endogenous opioids) (2)Pregnancy(3)Stimulation of nipples (4) Sleep (5) Idiopathic.
[B] Hypothalamus & pituitary:-(1) Craniopharyngioma (2) Tuberculosis (3) Hypothyroidism (4) Multiple endocrine disorder (Cushing’s syndrome, Acromegaly) (5)Pituitary adenomas (Prolactinomas) (6) Resection of pituitary stalk.
[C]Drugs:-Some drugs, like antidepressants
[D] Others:- (1) Renal failure (2) Cirrhosis of liver (3) PCOS (4) Idiopathic. (J) SHEEHAN’S Syndrome:-There is history of severe postpartum haemorrhage, shock or severe infection. Depending upon the degree of anterior pituitary necrosis, the features vary. The common manifestations are failing lactation, loss of pubic & axillary hair, lethargy, hypotension, secondary amenorrhoea and atrophy of the breasts & genitalia. Gonadotrophin level is low, so also T3,T4 and cortisol. The hormones affected in order of frequency are, growth hormone (GH), prolactin, Gonadotrophins(FSH and LH), TSH and ACTH (Adrenocorticotrophic hormone). Hyponatremia may be present (30%). The syndrome may develop slowly over 8-10 years time. (K)Adrenal Tumour or Hyperplasia:-There is secondary amenorrhoea, infertility, acne and features of defeminisation followed by virilisation(hoarness of voice, hirsutism and enlargement of clitoris). In both the conditions there is excess production of androgens. Serum level of DHEA-S (dehydroepiandrosterone sulphate) correlates well with daily urinary 17KS excretion. (L) Cushing syndrome:- Cushing first described the syndrome in 1932. Androgens are formed as intermediate products in the synthesis of cortisol. The elevated cortisol level found in Cushing syndrome encompasses two distinct pathologic entities- (1) Cushing disease(ACTH dependent) (2) Adrenal tumour(ACTH independent).
syndrome; In Cushing disease, there is excess production of ACTH from the anterior pituitary or from ectopic sites. The increased ACTH causes hyperstimulation of adrenal cortex leading to its hyperplasia which in turn leads to excess production of cortisol & androgens. ACTH independent causes(adrenal adenoma or cancer) may be iatrogenic(high dose corticosteroid therapy)or adrenal tumour. The cause of adrenal mischief is cortisol secreting adenoma which produces excess cortisol. The androgen production is usually less but may be markedly elevated in presence of adrenal carcinoma. Symptoms include:-weakness, oligomenorrhoea, amenorrhoea, acne and hirsutism. Virilism is rare. The syndrome is often associated with hypertension, osteoporosis and insulin dependent diabetes. (M) Thyroid Dysfunction:- Both hypo & hyperthyroid states may produce secondary amenorrhoea & anovulation, the former is common. Serum TSH is raised, while T3 and T4 values are lowered in hypothyroid state. In subclinical hypothyroid state,serum TSH is elevated but T4 is normal. Serum prolactin may be raised even beyond 20ng/ml in hypothyroid state. This is due to increased sensitivity of prolactin secreting cells of anterior pituitary to TRH (Thyroid Releasing Hormone). (N) Postpill Amenorrhoea:-It is observed in less than 1% of the women following the use of COC pills (Combined Oral Contraceptive) pills. The association is more coincidental rather than causal. Fertility rate is normal following discontinuation of the drug. Spontaneous resumption of menstruation occurs in majority of cases after a varying period. Otherwise such amenorrhoea should be investigated as in other cases of secondary amenorrhoea. (O) General disease:- Malnutrition, tuberculosis- both pulmonary & pelvic, diabetes & chronic nephritis are all implicated. Their diagnostic criteria vary accordingly. Straight X-ray chest in pulmonary tuberculosis, blood sugar in diabetes, urine analysis & blood urea in chronic nephritis are helpful to substantiate the diagnosis.
[INVESTIGATIONS]:-Investigations aims at:- (1)To diagnose or confirm the offending factor. (2)To guide the management protocol either to restore menstruation and/or fertility.
General examination:-The following features are to be noted-(1)Nutritional status(2)Extreme emaciation or marked obesity(3)Presence of acne or hirsutism (4)Discharge of milk from breast.
Writer
Dr Priyanka
