Treatment of Prolactinomas
Author: Christopher Anthistle
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Treatment of ProlactinomasAuthor: Christopher Anthistle |
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This web site provides easy access to published medical research findings about a type of pituitary tumor which produces an excess of the hormone prolactin. This tumor is known as a prolactinoma, it is very very rarely malignant and can usually be controlled by medication. My emphasis is on treatment options rather than patients sharing experiences (on line support). Both aspects are important, but I think getting the facts first before sharing improves the overall quality of support messages and prevents you from being misled by a support message posted by someone who means well but doesn't know what he or she is talking about. Also, some other pituitary sites handle the sharing aspect much better than I ever could, facts is what I do best. There are links here to other prolactinoma pages, including pages more oriented to support.
This web site will be of interest to prolactinoma patients, their families and doctors, and to medical students. Patients and families often have difficulty finding good prolactinoma information. In my efforts to correct that I may even have provided too much information here, so I apologize if you have to wade through some seemingly boring stuff to find those golden nuggets you are particularly interested in.
I am not a doctor, and have no medical training, but somebody close to me, a family member, has a prolactinoma and polycystic ovaries so I developed an interest in finding and reading medical research on the subject. Specialists who see prolactinoma and other pituitary patients frequently should know most of this (if they have the time to tell you) but general practitioners see this condition so rarely they usually do not have much knowledge about it. This leads to the condition being under diagnosed.
If you are female and your period has stopped and no reason can be found, or if you are of either gender and have lost interest in sex for no apparent reason, particularly if you have also been having headaches or discharge from your breasts, ask your doctor to order a simple blood test to check your prolactin. These tumors do not always cause headaches or breast leakage, so lack of these symptoms does not mean no tumour. If the blood test shows high prolactin ask your doctor for a referral to an endocrinologist. Depending on how high your prolactin is either your doctor or the endocrinologist may order an MRI scan of your pituitary (painless, none invasive) to see whether or not a tumor is present.
This web page is offered for information only, consult with your doctor for specific personal recommendations.
If you have knowledge of what a prolactinoma is, treatment options, symptoms, where the pituitary is located and what prolactin is then you can save some reading by scrolling or paging down to the heading "Abstracts" (or click here)
First some basics, a prolactinoma is a tumor of the pituitary gland and this particular type of tumor produces an excess of the hormone prolactin. If the tumor compresses the optic chiasm (where the optic nerves cross, located just above the pituitary) you may develop some loss of peripheral vision (seeing to the sides) which you may not notice without a special eye test. This may or may not return to normal as the tumor is brought under control.
High prolactin causes reduction in libido (sex drive) in both sexes, may cause impotence in the male, switches off the ovaries (stops conception and the monthly period) in females, also may cause milk to be produced in the breasts and may cause headaches (breast milk and/or headaches are not always present). The good news is that there is an excellent chance this will all reverse itself if the tumor is brought under control and the prolactin level drops. There also is some evidence of subtle psychological or personality changes, a possibility that memory is not as good as it once was, and maybe some increased body weight.
It is very, very, rare for this type of tumor to be cancerous (capable of spreading to other locations in the body), though it is somewhat less rare for them to be invasive (capable of growing through the confines of the bony shell the pituitary lives in). Growth of the tumor can be monitored with MRI scans (or CT scans where MRI is not available). MRI and CT are none invasive procedures, no pain, no anesthetic. Don't panic and think your days are numbered after diagnosis. This is a major event in your life, it will result in some worry and inconvenience, and the medication may not agree with you, but you should be able to live out a normal life span. Most prolactinomas can be controlled (growth stopped or even shrunk, hormone output reduced or normalized) by medication, others might need surgery (usually through the nose or through an incision behind the upper lip) and as a last resort some might need radiation.
Since radiation is generally considered a last resort I am not going to include it here except for some general observations. Radiation has risks of destruction of the pituitary, late onset brain and optic chiasm necrosis, possibly even brain cancer. The beneficial effects of radiation may not be felt for a year or two, and the deleterious effects may not be felt for 8 or 10 years or more. Gamma knife radiosurgery, where available, might reduce these risks as most of the radiation is tightly focused in the target area. If it is necessary, radiation should be discussed with an expert in the field and lots of personal research done to verify what percentages of risk there are and whether these are acceptable to you.
Images of brain and nose and definitions of pituitary gland and prolactin from Grolier Electronic Publishing, Inc. Copyright - 1993
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The endocrine gland known as the pituitary, or hypophysis, is situated at the base of the brain and is connected to the hypothalamus by a stalk. Structurally, it looks like a cherry and is comprised of anterior, intermediate, and posterior lobes.
The anterior lobe secretes six protein hormones: GROWTH HORMONE, which promotes body growth; PROLACTIN, which stimulates the production of milk; ADRENOCORTICOTROPIC HORMONE (ACTH), which stimulates the adrenal cortex; thyroid stimulating hormone (TSH); and two gonadotropic hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The latter two control the maturation and function of the ovaries and testes. The anterior pituitary is connected by blood vessels to the hypothalamus, which secretes hormones that regulate the function of these six hormones.
The intermediate lobe secretes melanocyte-stimulating hormone (MSH), which temporarily darkens the skin of cold-blooded animals for purposes of camouflage as well as for aggressive and mating behavior. It has little, if any, functional significance, however, in humans.
The posterior lobe has direct nerve connections with the brain. It stores and releases two peptide hormones produced by the hypothalamus: OXYTOCIN, which stimulates uterine contractions during childbirth and initiates the milk letdown response in nursing mothers; and vasopressin, an ANTIDIURETIC HORMONE (ADH) that acts on the kidneys to prevent excess loss of body water. An insufficiency of ADH results in DIABETES insipidus, a disease characterized by extremely high water intake and high volume of excreted urine.
Removal or destruction of the pituitary stops body growth, inhibits milk secretion, and causes the adrenal glands, the thyroid gland, and the gonads to shrink in size and to cease functioning, except for continuing regulation of salt and water metabolism by the adrenal cortex. Excess secretion of the pituitary, conversely, can cause gigantism as well as abnormally alter the function of the adrenals, the thyroid, and the gonads.
Prolactin is an endocrine hormone secreted by the anterior portion of the pituitary gland, or hypophysis. It provokes milk secretion in mammary glands that have been fully developed by other endocrine hormones during pregnancy. Prolactin does not act unless other pituitary substances are present, however.
The following are abstracts from medical journals (author's summaries of the complete text of their published papers) published in the last few years. These are not all of the papers published on the subject, they have been selected to give the prolactinoma patient and/or his or her family (or even general practitioner) an overview of treatment by medication and surgery. Much of the surgery part also applies to other types of pituitary tumors.
Also, the newer drugs mentioned may not normally be available in Canada but it may be possible to get Federal Government (Health Canada) permission to use them under the Special Access Programme if the standard Bromocriptine (Parlodel) either does not work for you or causes severe side effects (talk to your doctor). Taking part in a drug trial is another possibility (if you can find one). There is also an injectable form of Bromocriptine that only needs to be taken once a month. The following text is contact information for the Health Canada Special Access Programme, your doctor or specialist should be the one to make contact. Note that Cabergoline (Dostinex) is expected to be approved for use in Canada in (or soon after) July 2000. (For further Canadian Dostinex information contact Pharmacia & Upjohn Inc., 5100 Spectrum Way, Mississauga, Ontario, Canada L4W 5J5)
Special Access Programme
Therapeutic Products Directorate
Holand Cross, Tower "B"
1600 Scott Street, 3rd floor
OTTAWA, ON
K1A 1B6
Postal Locator 3103B
Telephone: (613) 941-2108 (08:30-16:30 hours EST)
(613) 941-3061 (after hours)
Fax (613) 941-3194
Other countries may have similar programs for their residents.
Your web browser determines the font size used to display these abstracts. If the line length is greater than the screen width it is because too large a font is being used. To avoid having to use horizontal scrolling reduce the font size for Preformatted Text (PRE), try Courier New, Regular, 10 point. This can usually be done from the menu bar by clicking on Preferences, Font and Background, or something similar depending on the browser.
Abbreviated Journal name, issue and page reference, is on the lines that start with "SO - " or "SOURCE: ". If you want the full text of the paper try a Health Sciences Library (at a University that has a medical school) or possibly a Hospital Medical Library. Note that some of these are in technical language as they were intended for a physician audience - the abstracts were written by the authors of the papers and summarise the content of the paper.
(now distributed by Pharmacia Upjohn, in the USA their brand name is Dostinex, and in the U.K. it is Cabaser)
(Manufactured by Sandoz, or their subsidiary Novartis, brand name is Norprolac. In its earlier days it used to be called CV 205-502 and additional abstracts may be found in the medical databases under that name)
2 (b) Recent surgical abstracts
2 (c) A new surgical approach (Endoscopy assisted transsphenoidal)
4 (a) Pregnancy for prolactinoma patients
4 (b) Body weight changes associated with prolactinoma
4 (c) Possible future developments in prolactinoma treatment
4 (d) Possible herbal supplements for prolactinoma
MEDLINE is a database containing summaries (abstracts) of medical journal articles written by doctors researching diseases, medications, treatments. It can be accessed for free from various places on the web but there seems to be a tendency towards portals requiring registration to access it. I consider registration for web sites to be an invasion of privacy so I always avoid it, or provide false information where it cannot be avoided. Registration is only more annoyance from marketers, why let them target you. For the same reasons I also frequently delete internet cookies from my hard drive.
| There is a site in Hungary (Center for Culture & Communication http://www.c3.hu/ ) that has some full text english language medical journal articles concerning the pituitary. Access the site and click on SE (Search) then search on pituitary as more may have been added since I wrote this (7/2000). The following are articles that I found particularly interesting (click on the underlined titles to retrieve them): |
| Bromocriptine
therapy for prolactin-secreting pituitary adenomas Edward R. Laws, Jr., M.D., Michael O. Thorner, M.D., and Mary L. Vance, M.D. Departments of Neurosurgery and Internal Medicine, University of Virginia Health Sciences Center, Charlottesville, Virginia |
| A
technique for endoscopic pituitary tumor removal Michael D. Cusimano, M.D., M.H.P.E., F.R.C.S.C., and Ronald S. Fenton, M.D., F.R.C.S.C. Division of Neurosurgery and Department of Otolaryngology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada |
| Endoscopic
endonasal transsphenoidal surgery: experience with 50
patients Hae-Dong Jho, M.D., Ph.D., and Ricardo L. Carrau, M.D. Departments of Neurological Surgery and Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania |
| Symptoms
of pituitary apoplexy rapidly reversed with bromocriptine
Michael H. Brisman, M.D., Gillian Katz, M.D., and Kalmon D. Post, M.D. Departments of Neurosurgery and Endocrinology, The Mount Sinai Medical Center, New York, New York |
| Defining
postoperative values for successful resection of
prolactinomas William T. Couldwell, M.D., Ph.D., and Martin H. Weiss, M.D. Departments of Surgery and Neuroscience, University of North Dakota, Minot, North Dakota; and Department of Neurosurgery, University of Southern California, Los Angeles, California |
| Radiation-induced
meningioma following radiation therapy for pituitary
adenoma Mark K. Lyons, M.D., Gilbert R. Gonzales, M.D., Steven E. Schild, M.D., and Kent D. Nelson, M.D. Departments of Neurological Surgery, Neurology, Radiation Oncology, and Diagnostic Radiology, Mayo Clinic, Scottsdale, Arizona |
| This
one is a must read for pituitary patients considering
surgery Complications
of Transsphenoidal Surgery: Results of a National Survey,
Review of the Literature, and Personal Experience |
Another interesting full text article from a different source (Frontiers in Bioscience 3, d934-943, August 6, 1998) discusses the possible role of Estrogen and other factors in prolactinomas (click underlined title to retrieve)
HORMONAL
CONTROL OF PITUITARY PROLACTIN-SECRETING TUMORS
Dipak K. Sarkar, Shane T. Hentges, Alok De and Raghaba H.R. Reddy
Department of Veterinary and Comparative Anatomy, Physiology and
Pharmacology, Washington State University, Pullman, WA 99163-6540
Click here for list of medications Notice I said can cause, not will cause, it is just that it is listed by the manufacturer's as a possible side effect of this medication. If you have no tumour and no reason can be found for your high prolactin and you happen to be on one of these medications then you might want to ask your pharmacist to suggest an alternate medication that would treat your condition without this side effect. Discuss the pharmacists recommendation with your doctor, if the doctor thinks it is worth changing your medication give it a trial and see if your prolactin goes down. If there is no effect on prolactin then stay with the medication that suits you best.
The following links were copied from the results of searching prolactinoma on the internal search engine at Karolinska Institute (Stockholm, Sweden) who have extensive information and links on all types of diseases. You may also wish to check their site for additional prolactinoma links since July 2000.
Canadians looking to join a group may prefer to join The Pituitary Tumor Support Network of Canada (no web link yet). They held their First International Conference in Toronto (North York City Hall) on Saturday May 1st and Sunday May 2nd 1999. It was excellent, well attended by patients, and with many distinguished Canadian pituitary doctors donating their time to give presentations (some of whom are known internationally for their work in the pituitary field). Their presentations were video taped at the conference so copies of the tapes may still be available. There is a newsletter, and regular meetings in downtown Toronto. Chapters are forming in other parts of Canada. There is an annual fee. For more information contact:
The Pituitary Tumour Support Network of Canada St. Michael's Hospital / West Annex 26 Shuter Street, Rm 002 Toronto Ontario CANADA M5B 2P8 Telephone: 1 416 864 5469 Fax: 1 416 864 5451
(Fax available only when a volunteer is staffing the office, if fax fails try again during daytime weekdays or call voice to check if anyone is in)
If you are a female with prolactinoma my personal opinion is you should ask your doctor for a pelvic ultrasound to check if you also have polycystic ovaries. It sometimes happens they both occur together. If you do have polycystic ovaries then you will want to check these links and you might also want your doctor to check for insulin resistance, cholesterol and blood lipids, LH, FSH, estrogen, and testosterone (yes females do have some testosterone and it is usually higher than normal with polycystic ovaries). With this type of polycystic ovaries (associated with prolactinoma) it is also likely that estrogen will be lower than normal. There has been some controversy about supplementing estrogen (or taking estrogen containing birth control pills) as prolactinomas can have estrogen receptors that were thought to be a cause of growth. Some doctors now feel that moderate estrogen use does not cause tumor growth, but it may be a case where "the jury is still out" so discuss this with your doctor.
There are also many women on the web with their own polycystic ovaries page such as: Dawn's Polycystic Ovarian Syndrome and Brianna's PCOS Pages Brianna includes information on herbal treatments but if you have loading graphics disabled you may need to reactivate it or change your browser page colors to read her page as her text color choice relies on a dark blue background graphic being visible. (Hers is the one below the Geocities advertisement).
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This Page Last Updated on 14th. May, 2001 (for transfer to Yahoo! Canada GeoCities)
