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Hyperprolactinemia , hirsutisim,virilization

Hyperprolactinemia , hirsutisim,virilization. Dr. Thabat Al-Mayahi MBChB, DOG, CABOG 2017 -2018. Prolactin hormone. made by the pituitary lactotrophs . Normal serum level= 10- 25 ng /ml, half life =20 minutes Metabolized in the liver and kidny. Control of prolactin release:.

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Hyperprolactinemia , hirsutisim,virilization

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  1. Hyperprolactinemia , hirsutisim,virilization Dr. Thabat Al-Mayahi MBChB, DOG, CABOG 2017 -2018

  2. Prolactin hormone made by the pituitary lactotrophs. Normal serum level= 10- 25 ng/ml, half life =20 minutes Metabolized in the liver and kidny

  3. Control of prolactin release: • Prolactin inhibiting factor (dopamine) → ↓ prolactin • Estrogen → ↑ prolactin • TRH “thyrotropin releasing hormone” → ↑ prolactin

  4. How does prolactin act? A- Inhibition of pulsatile GnRH secretion B-decreas ovarian sensetivity to gonadotrophines C-Inhibition of FSH-directed ovarian aromatase D-Inhibition of progesterone synthesis

  5. Causes of hyperprolactinemia Physiologic conditions • Sleep • Satinity • Sex • Sucking • Second half of menestural cycle • Stress and excersise

  6. Pharmacological • Estrogen containing drugs/ pills • Antidopaminergic druges---TCA • Antiemetic druges----metoclopramid • Antihypertensive druges-----methyldopa • H2 receptor antagonist • Druges that stemulat serotonin secreation---hallucinogenes

  7. Pathological • Pituitary---adenoma,GHsecreating tumor • Hypothalomuse—infection,truma,tumor • Thyroid gland---hypothyroidisim

  8. Other causes • Liver cell failure- Chronic renal failure. • Chest wall disease: burn- scar- Herpes zoster • Ectopic secretion:Hypernephroma of • kidney. • Oat cell carcinoma of lung • Hyperestrogenic----PCOS

  9. Clinical Manifestation • Galactorrhea---30% • Infertility---due to luteal phase anovulation • Oligohypomenorrhea • Decreased libido • Hirsutism—due to decrease in SHBG

  10. DIAGNOSES • HISTORY • EXAMINATIO---eyes,thyroid,breast,chest wall • INVESTIGATIONES--prolactin level > 100 ng / ml—sugestive adenoma > 300 ng/ ml---diagnostic adenoma > 2000 ng/ ml ---cavernusesinuse invasion • Thyroid function test • Liver function test • Kidny function test

  11. Brain MRI macroadenoma (> 1cm). microadenoma(<1cm)

  12. Treatment • Treate the cause • Dopamine agonists:Bromocreptine (parlodel)

  13. Lisuride(dopergine) More potent Less side effectes Cabergoline(dostinex) Longer half life

  14. Quinagolid(norprolac) non-ergot preparation Less side effect

  15. surgery • Trans sphenoidal resection

  16. HIRSUTISM

  17. HIRSUTISM: excessive growth of androgen-dependant hair in an abnormal sites of female body (beard, nostrils, upper lip, chest, abdomen, extensors of arms & back of the trunk) associated with loss of cyclic menstrual pattern.

  18. TYPES OF ANDROGENS IN FEMALES: 1. Androstendione ( AD) = [1.4 ng/ml] 2.Dehydro-epiandrosterone( DHEA) =[4-10 ng/ml] 3.Dehydroepiandrosteronesulfate(DHEAS)=[1.4μg/ml] 4. Testosterone ( T ) = [0.4-1ng/ml] 5. Di-hydrotestosterone ( DHT ) =[0.1-0.3 ng/ml] 6. 3 alpha Androstenediole glucoronide ( 3 α-Diole G ) OR (3 α AG)

  19. ØTestosterone : a measure of ovarian & adrenal activity Ø DHEA-S- measure of adrenal activity ØMarker of peripheral target tissue androgen is 3 a-AG (androstanediol glucuronide) (not measured as routine; less clinical significant ) Ø DHT is the intracellular active form of T and it is twice potent as T and produced from T under the effect of 5 alpha reductase enzyme

  20. ETILOGY OF HIRSUTISM PHYSIOLOGICAL : 3P (A). PUBERTY; due to increased adrenal androgens before ovarian estrogens (B). PREGNANCY: unexplained (C). POSTMENOPAUSE: due to relative increase of androgen from the adrenal and ovary

  21. IDIOPATHIC HIRSUTISMØ The commonest type. More in mediterranean women due to increased activity of 5α- reductase enzyme. Ø To consider the case as idiopathic there must be: 1- normal menstrual pattern 2- normal or slightly increased androgens especially 3 α AG

  22. 3- OVARIAN CAUSES: (a). Hyperthecosis of the ovaries • (b). Polycystic ovary syndrome (PCOS) (c). Androgen secreting ovarian tumors (d).lutoma of pregnancy • The condition is diagnosed as ovarian neoplasm if: • 1- serum testosterone is > 2ng/ml or • 2- serum testosterone is > 2.5 fold the normal

  23. ANDROGEN PRODUCING OVARIAN TUMORS 1. Sertoli-Lyedig cell tumor 2. Hilus-cell tumor 3. Lipoid cell tumor 4. OTHERS: [a]. Malignant cystadenocarcinoma [b]. Brenner’s tumor [c]. Krukenberg’s tumor

  24. ADRENAL CAUSES A.Congenital adrenal hyperplasia (CAH): 3 forms/presentations: Ø infantile CAH= female pseudohermaphrodite Ø pre-pubertal = precocious puberty Ø adult type= virilism B. Cushing’s syndrome:overproduction of cortisol by adrenal cortex due to: i. overproduction of ACTH by pituitary (Cushing’s disease) ii. Ectopic ACTH by non-pituitary tumor iii. Autonomous secretion of cortisol by adrenal or ovarian tumors iv. Ectopic corticotropin-releasing hormone production C. Adrenal tumors : DHEA-S > 8μg/ml (normal 1-4 μg/ml)

  25. OTHER CAUSES: A. Iatrogenic (drugs): androgens, norgestrel, danazole, diazoxide, dilantin B. Incomplete testicular feminization syndrome: (Refenstien’s syndrome) C. RARE TYPES : Ø acromegaly Ø porpheria Ø DES- exposed female infant

  26. EVALUATION OF HIRSUTISM • History • Examination----Distribution of excess hair growth BODY BUILT Signs of virilization ABDOMINAL EXAMINATION • Investigations

  27. MANAGEMENT OF HIRSUTISM q General measures qAntiandrogens: 1. cyproterone acetate (CPA) 2. Spironolactone (aldactone) 3. Flutamide 4. Ketoconazole qOvarian supression 1. COCs 2. GnRHa q Adrenal suppression DEXAMETHAZONE ( 0.25-0.5 mg) taken at night suppress ACTH morning surge & adrenal production of androgens q Finasteride q Surgical measures

  28. Finasteride (proscar) 5 α reductase inhibitor used in cases of idiopathic hirsutism - it is non steroidal compound exerting specific competitive inhibition with 5 α reductase thus decreases the conversion of testosterone into intracelluar active DHT, decreasing hirsutism Dose: 5mg /day

  29. Surgical procedures 1. ovarian wedge resection (old fashion treatment replaced by laparoscopic ovarian drilling ) 2. bilateral oophorectomy 3. surgical treatment of the cause (if indicated )

  30. VIRILIZATION is more severe condition of androgen excess in female; it includes combination of hirsutism & musculinity,clitoromegaly,deepening of voice, balding, and changes of body habitus (eg: increas muscle mass, decreased breast size)

  31. THANK YOU

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