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 pituitaryhypothalamic disease, especially if accompanied by amenorrhea

NO FEATURES OF ANDROGEN EXCESS

Physiological,
e.g. pregnancy, lactation, menopause
PRESENT
Iatrogenic,
e.g. depot medroxyprogesterone
acetate contraceptive
ETIOLOGIES
OF SECUNDARY
injection, radiotherapy, chemotherapy
AMENORRHOEA
Systemic disease, e.g. chronic illness, hypo- or hyperthyroidism

Uterine causes, e.g. cervical stenosis, Asherman's syndrome (intrauterine 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)
Thyrotropin (TRH)
Corticotropin (CRH)
Growth-Hormone (GHRH)

Somatostatin
Prolactin Inhibiting Factor
(PIF)

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
Pathological
causes
HYPERPROLACTINEMIA

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
Oligomenorea,
e
(makroadenoma
)
amenore
Headache
Subfertil

Hilang visus

Galaktorea

Neuropati kranial

Penurunan libido

Kejang

Osteopenia

Rhinorea cairan
serebrospinal

APPROACH TO DIAGNOSIS OF
HYPERPROLACTINEMIA
Prolactine level
Macropro
lactinemia

Repeat
Rule out secondary
measurement
causes
Correct underline
Pathological
hyperprolactinemia cause: Replace
thyroid hormone
etc.
MRI Pituitary

Normal

Micro lesion

Asymptomatic Symptomatic
Follow up prolactin
Treatment
measurement

Macro lesion

TERIMA KASIH

Thanks Young
Docters