Case Report Published on 14 Mar, 2024

Prolactinoma Presenting with Secondary Amenorrhoea in a Young Girl

Prolactinoma in a Young Woman
Vol. 19 No. 1 : 2024 (292-299)

2halima hana ak1 2halima hana ak1
Leelavathi M2 Leelavathi M2
Katiman E3 Katiman E3
NA Aziz2 NA Aziz2

Abstract
Prolactinoma is the most common secreting pituitary adenoma. It has different clinical presentation in men and women which varies with age. Young women present with menstrual problems, infertility and galactorrhoea, whilst older women and men may present with loss of libido, visual disturbances and in late cases, with osteoporosis. In approaching a young woman with secondary amenorrhoea, other causes such as pregnancy, functional hypothalamic amenorrhea, pituitary adenoma, Polycystic Ovarian Syndrome (PCOS) or primary ovarian insufficiency should be ruled out. Prolactinoma can be confirmed in the presence of high serum prolactin level and adenoma on pituitary gland magnetic resonance imaging (MRI). Dopaminergic agonist, cabergoline is efficacious in restoring gonadal and sexual functions by normalising prolactin levels. We presented a case report on an 18-year-old girl who presented with secondary amenorrhoea for six months. On further evaluation she was noted to have galactorrhoea with substantially high prolactin level of 466.9 ng/mL (normal range: 4.0- 23) and the MRI showed a pituitary tumour measuring 1.2 x 1.1 x 1.4 cm. A diagnosis of macroprolactinoma was made and she was managed with cabergoline with gradual dose increment. At 6 months of treatment, her menstrual cycle and serum prolactin had normalised.  A repeat MRI pituitary one year later showed reduction in tumour size.
Keywords : Amenorrhoea, galactorrhoea, pituitary adenoma, prolactinoma,
Abstrak
   Prolaktinoma merupakan adenoma pituitari yang paling lazim dijumpai. Presentasi klinikal pada lelaki dan wanita adalah berbeza mengikut umur. Wanita muda lazimnya mengalami masalah kitaran haid, ketidaksuburan dan "galactorrhoea" manakala lelaki dan wanita warga emas lazimnya mengalami kekurangan libido, gangguan penglihatan dan sekiranya lambat dikesan, mungkin mengalami komplikasi seperti osteoporosis. Punca putus haid melebihi tempoh tiga bulan di kalangan wanita yang sebelumnya mempunyai kitaran haid yang normal perlu disiasat kerana ia mungkin disebabkan oleh kehamilan, masalah hypothalamus, masalah kelenjar pituitary atau Sindrom Polycystic Ovarian (PCOS). Prolaktinoma dapat disahkan apabila tahap prolaktin dalam darah adalah tinggi dan adenoma dikesan pada pengimejan resonans magnetik (MRI) kelenjar pituitari. Ubat dopaminergik agonis seperti cabergoline amat berkesan untuk menurunkan tahap prolaktin kembali ke paras normal dan membolehkan fungsi gonad dan seksual pesakit kembali seperti sediakala. Kami membentangkan laporan kes mengenai seorang gadis berusia 18 tahun yang mengalami masalah kitaran haid yang tidak teratur. Tahap prolaktin yang tinggi, 466.9 ng/mL (tahap normal: 4.0- 23) serta MRI pituitari yang menunjukkan tumor berukuran 1.2 x 1.1 x 1.4 cm, mengesahkan bahawa pesakit mengalami masalah makroprolaktinoma. Selepas enam bulan rawatan dengan ubat cabergoline, kitaran haid dan tahap prolaktin pesakit telah kembali normal.  MRI pituitari pula menunjukkan pengurangan saiz ketumbuhan selepas setahun menerima rawatan.
Kata Kunci : Adenoma pituitari, amenoria, galaktoria, prolaktinoma,

Correspondance Address
Assoc. Prof. Dr. Leelavathi Muthupalaniappen. Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia. Tel: +603-9145 9475 Email: drleelaraj@gmail.com

References
Auriemma, R.S., Pirchio, R., Pivonello, C., Garifalos, F., Colao, A., Pivonello, R. 2023. Approach to the patient with prolactinoma. J Clin Endocrinol Metab 108(9): 2400-23.

Borhan, M.K., Tan, F.H.S. 2022. Aggressive giant prolactinoma: A case report. J Med Case Rep 16(1): 170.

Cozzi, R., Ambrosio, M.R., Attanasio, R., et al. 2022. Italian association of clinical endocrinologists (AME) and international chapter of clinical endocrinology (ICCE). Position statement for clinical practice: Prolactin-secreting tumors. Eur J Endocrinol 186(3): P1-33.

Daly, A.F., Beckers, A. 2020. The epidemiology of pituitary adenomas. Endocrinol Metab Clin North Am 49(3): 347-55.

Gosi, S.K.Y., Garla, V.V. Galactorrhea. 2023. In StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK537115/ [April 2023]

Hordejuk, D., Cheung, Y.M., Wang, W., Smith, T., Laws, E., Kaiser, U.B., Min, L. 2023. Long-term changes in the size of pituitary microadenomas. Ann Intern Med 176(3): 298-302.

Huang, W., Molitch, M.E. 2012. Evaluation and management of galactorrhea. Am Fam Physician 85(11): 1073-80.

Inder, W.J., Jang, C. 2022. Treatment of prolactinoma. Medicina (Kaunas) 58(8): 1095.

Karl, D., Gillan, S.N., Goudie, C., Sanders, R. 2015. Giant prolactinoma mimicking low-tension glaucoma at presentation. BMJ Case Rep 2015: bcr2014207634.

Lake, M.G., Krook, L.S., Cruz, S.V. 2013. Pituitary adenomas: An overview. Am Fam Physician 88(5): 319-27.

Li, D., Wang, Y., Tan, H., Luo, P., Yu, Y. 2023. A giant invasive macroprolactinoma with recurrent nasal bleeding as the first clinical presentation: Case report and review of literature. BMC Endocr Disord 23(1): 107.

Martin, N. 2020. Prolactinoma, BMJ Best Practice. https://bestpractice.bmj.com/search?q=prolactinoma [May 2021]

Petersenn, S., Giustina, A. 2020. Diagnosis and management of prolactinomas: Current challenges. Pituitary 23(1): 1-2.

Pérez Pinzón, J., González-Devia, D., Kattah Calderón, W., López Panqueva, R.D.P., Jiménez Hakim, E. 2019. Unusual course of an aggressive pituitary prolactinoma: Case report and review of the literature. Case Rep Neurol 11(1): 148-56.

Synder, P., Cooper, D.S., Martin, K.A. 2020. Causes, presentation, and evaluation of sellar masses – UpToDate. https://medilib.ir/uptodate/show/6632 [May 2021]

Welt, C.K., Barbieri, R.L., Crowley, W.F., Geffner, M.E., Martin, K.A. 2023. Evaluation and management of secondary amenorrhea. https://www.ncbi.nlm.nih.gov/books/NBK279144/ [April 2023]

Yagnik, K.J., Erickson, D., Bancos, I., Atkinson, J.L. D., Choby, G., Peris-Celda, M., Van Gompel, J.J. 2021. Surgical outcomes of medically failed prolactinomas: A systematic review and meta-analysis. Pituitary 24(6): 978-88.

Zou, Y., Li, D., Gu, J., Chen, S., Wen, X., Dong, J., Jiang, X. 2021. The recurrence of prolactinoma after withdrawal of dopamine agonist: A systematic review and meta-analysis. BMC Endocr Disord 21(1): 225.
Correspondance Address

Auriemma, R.S., Pirchio, R., Pivonello, C., Garifalos, F., Colao, A., Pivonello, R. 2023. Approach to the patient with prolactinoma. J Clin Endocrinol Metab 108(9): 2400-23.

Borhan, M.K., Tan, F.H.S. 2022. Aggressive giant prolactinoma: A case report. J Med Case Rep 16(1): 170.

Cozzi, R., Ambrosio, M.R., Attanasio, R., et al. 2022. Italian association of clinical endocrinologists (AME) and international chapter of clinical endocrinology (ICCE). Position statement for clinical practice: Prolactin-secreting tumors. Eur J Endocrinol 186(3): P1-33.

Daly, A.F., Beckers, A. 2020. The epidemiology of pituitary adenomas. Endocrinol Metab Clin North Am 49(3): 347-55.

Gosi, S.K.Y., Garla, V.V. Galactorrhea. 2023. In StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK537115/ [April 2023]

Hordejuk, D., Cheung, Y.M., Wang, W., Smith, T., Laws, E., Kaiser, U.B., Min, L. 2023. Long-term changes in the size of pituitary microadenomas. Ann Intern Med 176(3): 298-302.

Huang, W., Molitch, M.E. 2012. Evaluation and management of galactorrhea. Am Fam Physician 85(11): 1073-80.

Inder, W.J., Jang, C. 2022. Treatment of prolactinoma. Medicina (Kaunas) 58(8): 1095.

Karl, D., Gillan, S.N., Goudie, C., Sanders, R. 2015. Giant prolactinoma mimicking low-tension glaucoma at presentation. BMJ Case Rep 2015: bcr2014207634.

Lake, M.G., Krook, L.S., Cruz, S.V. 2013. Pituitary adenomas: An overview. Am Fam Physician 88(5): 319-27.

Li, D., Wang, Y., Tan, H., Luo, P., Yu, Y. 2023. A giant invasive macroprolactinoma with recurrent nasal bleeding as the first clinical presentation: Case report and review of literature. BMC Endocr Disord 23(1): 107.

Martin, N. 2020. Prolactinoma, BMJ Best Practice. https://bestpractice.bmj.com/search?q=prolactinoma [May 2021]

Petersenn, S., Giustina, A. 2020. Diagnosis and management of prolactinomas: Current challenges. Pituitary 23(1): 1-2.

Pérez Pinzón, J., González-Devia, D., Kattah Calderón, W., López Panqueva, R.D.P., Jiménez Hakim, E. 2019. Unusual course of an aggressive pituitary prolactinoma: Case report and review of the literature. Case Rep Neurol 11(1): 148-56.

Synder, P., Cooper, D.S., Martin, K.A. 2020. Causes, presentation, and evaluation of sellar masses – UpToDate. https://medilib.ir/uptodate/show/6632 [May 2021]

Welt, C.K., Barbieri, R.L., Crowley, W.F., Geffner, M.E., Martin, K.A. 2023. Evaluation and management of secondary amenorrhea. https://www.ncbi.nlm.nih.gov/books/NBK279144/ [April 2023]

Yagnik, K.J., Erickson, D., Bancos, I., Atkinson, J.L. D., Choby, G., Peris-Celda, M., Van Gompel, J.J. 2021. Surgical outcomes of medically failed prolactinomas: A systematic review and meta-analysis. Pituitary 24(6): 978-88.

Zou, Y., Li, D., Gu, J., Chen, S., Wen, X., Dong, J., Jiang, X. 2021. The recurrence of prolactinoma after withdrawal of dopamine agonist: A systematic review and meta-analysis. BMC Endocr Disord 21(1): 225.



Auriemma, R.S., Pirchio, R., Pivonello, C., Garifalos, F., Colao, A., Pivonello, R. 2023. Approach to the patient with prolactinoma. J Clin Endocrinol Metab 108(9): 2400-23.

Borhan, M.K., Tan, F.H.S. 2022. Aggressive giant prolactinoma: A case report. J Med Case Rep 16(1): 170.

Cozzi, R., Ambrosio, M.R., Attanasio, R., et al. 2022. Italian association of clinical endocrinologists (AME) and international chapter of clinical endocrinology (ICCE). Position statement for clinical practice: Prolactin-secreting tumors. Eur J Endocrinol 186(3): P1-33.

Daly, A.F., Beckers, A. 2020. The epidemiology of pituitary adenomas. Endocrinol Metab Clin North Am 49(3): 347-55.

Gosi, S.K.Y., Garla, V.V. Galactorrhea. 2023. In StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK537115/ [April 2023]

Hordejuk, D., Cheung, Y.M., Wang, W., Smith, T., Laws, E., Kaiser, U.B., Min, L. 2023. Long-term changes in the size of pituitary microadenomas. Ann Intern Med 176(3): 298-302.

Huang, W., Molitch, M.E. 2012. Evaluation and management of galactorrhea. Am Fam Physician 85(11): 1073-80.

Inder, W.J., Jang, C. 2022. Treatment of prolactinoma. Medicina (Kaunas) 58(8): 1095.

Karl, D., Gillan, S.N., Goudie, C., Sanders, R. 2015. Giant prolactinoma mimicking low-tension glaucoma at presentation. BMJ Case Rep 2015: bcr2014207634.

Lake, M.G., Krook, L.S., Cruz, S.V. 2013. Pituitary adenomas: An overview. Am Fam Physician 88(5): 319-27.

Li, D., Wang, Y., Tan, H., Luo, P., Yu, Y. 2023. A giant invasive macroprolactinoma with recurrent nasal bleeding as the first clinical presentation: Case report and review of literature. BMC Endocr Disord 23(1): 107.

Martin, N. 2020. Prolactinoma, BMJ Best Practice. https://bestpractice.bmj.com/search?q=prolactinoma [May 2021]

Petersenn, S., Giustina, A. 2020. Diagnosis and management of prolactinomas: Current challenges. Pituitary 23(1): 1-2.

Pérez Pinzón, J., González-Devia, D., Kattah Calderón, W., López Panqueva, R.D.P., Jiménez Hakim, E. 2019. Unusual course of an aggressive pituitary prolactinoma: Case report and review of the literature. Case Rep Neurol 11(1): 148-56.

Synder, P., Cooper, D.S., Martin, K.A. 2020. Causes, presentation, and evaluation of sellar masses – UpToDate. https://medilib.ir/uptodate/show/6632 [May 2021]

Welt, C.K., Barbieri, R.L., Crowley, W.F., Geffner, M.E., Martin, K.A. 2023. Evaluation and management of secondary amenorrhea. https://www.ncbi.nlm.nih.gov/books/NBK279144/ [April 2023]

Yagnik, K.J., Erickson, D., Bancos, I., Atkinson, J.L. D., Choby, G., Peris-Celda, M., Van Gompel, J.J. 2021. Surgical outcomes of medically failed prolactinomas: A systematic review and meta-analysis. Pituitary 24(6): 978-88.

Zou, Y., Li, D., Gu, J., Chen, S., Wen, X., Dong, J., Jiang, X. 2021. The recurrence of prolactinoma after withdrawal of dopamine agonist: A systematic review and meta-analysis. BMC Endocr Disord 21(1): 225.