Case – pituitary adenoma

A 43 year-old woman to her gynecologist, complaints of

not having had a period for the last 8 months. She reports
a negative pregnancy test at home. On further
questioning, she reports daily headache, changes in vision,
and a milky discharge from the breast. She has no medical
problems and is not taking any medications. On physical
examination, she is noted to have galactorrhea and
diminished peripheral vision bilaterally. The remainder of
her examination is normal. A pregnancy test is repeated
and is negative. A thyroid-stimulating hormone (TSH) level
is drawn and is normal. Her serum prolactin level is
elevated significantly. After a thorough workup is
completed, she is found to have a prolactin-secreting
pituitary adenoma.
 Questions
• How does hyperprolactinemia cause
amenorrhea?
• Why would a physician need to check thyroid
studies in patients with hyperprolactinemia?
• Where are the posterior pituitary hormones
synthesized?
 OBJECTIVES
(PITUITARY GLAND)
1. Discuss the synthesis and secretion of the
hormones of the anterior and posterior
pituitary.
2. Describe the role of the hypothalamus in the
synthesis and secretion of the hormones of the
anterior and posterior pituitary.
3. Know the factors that increase and decrease
prolactin secretion.
 PITUITARY ADENOMA – imp points
Summary: A 43-year-old woman has secondary amenorrhea,
galactorrhea, headache and visual changes, and
hyperprolactinemia. She is diagnosed as having a pituitary
prolactinoma.
◊ Elevated prolactin and amenorrhea: Elevated prolactin levels
inhibit pulsatile gonadotropin-releasing hormone (GnRH)
secretion.
◊ Thyroid disease and elevated prolactin: Hypothyroidism is
associated with an elevated thyrotropin-releasing hormone (TRH)
level that increases the secretion of prolactin.
◊ Synthesis of the posterior pituitary hormones: Hypothalamic
nuclei—hormones are synthesized in nerve cell bodies, packaged
in secretory granules, and transported down the nerve axon to
the posterior pituitary.
 CLINICAL CORRELATION
• An elevated prolactin level can be seen in many conditions.
• Patients should be screened with a pregnancy test and thyroid
hormones.
• Contraceptives can cause an elevated prolactin level.
• Patients present with amenorrhea secondary to inhibition of GnRH
and/or galactorrhea.
• When adenomas are present, a patient may present with symptoms
of headache or even changes in vision. The visual changes
(bitemporal hemianopia) and headache usually are related to the
prolactinoma compressing the optic chiasm.
• Normally, prolactin inhibits its own secretion by stimulating the
release of dopamine (PIH) from the hypothalamus. However, when
pituitary adenomas are present, prolactin is secreted without
inhibition from normal feedback mechanisms.
 CLINICAL CORRELATION – Adenomas treatment

• Treatment of microadenomas that are not

symptomatic is usually medical with dopamine
agonist (apomorphine, ropinirole, bromocriptine –
beyond scope of this presentation).
• However, when microadenomas are symptomatic
or do not respond to medical management,
surgical intervention is often necessary.
• Macroadenomas usually are treated surgically.
 COMPREHENSION QUESTIONS
A 35-year-old woman experiences anterior pituitary
hemorrhagic necrosis (Sheehan syndrome) after a
postpartum hemorrhage. She feels light-headed, dizzy,
and weak. Which of the following hormones most likely
is responsible for her symptoms?
A. ACTH
B. GnRH
C. Prolactin
D. TSH
E. GH
 COMPREHENSION QUESTIONS
Answer – A. ACTH
• This female with anterior pituitary failure after
postpartum hemorrhage has symptoms of
dizziness and light-headedness.
• This probably is because of lack of ACTH and thus
lack of mineralocorticoids such as aldosterone.
• The inability to retain sodium leads to hypovolemia
and the symptoms of hypotension.
 DISCUSSION – prolactin
• The regulation of prolactin secretion differs from other
pituitary hormones. PRL secretion is under tonic
inhibition from the hypothalamus.
• If the hypothalamohypophysial portal system is
disrupted, PRL secretion increases rather than
decreases as is the case for the other pituitary
hormones.
• Most evidence points to dopamine rather than a
peptide as being the prolactin inhibitory hormone.
• In addition to this inhibitory pathway, PRL secretion can
be stimulated by TRH.
 DISCUSSION – prolactin
• The main target of PRL is the mammary gland, where
it promotes the secretion of colostrum and milk.
• PRL levels rise during pregnancy.
• After parturition, basal levels fall, but there are spikes
in PRL levels during and after periods of nursing.
• The spikes in PRL secretion are because of neural
signals from the breast acting at the level of the
hypothalamus to decrease dopamine release into the
hypothalamohypophysial portal system.
• This reflex and the high levels of PRL suppress the
hypothalamic secretion of GnRH, thus inhibiting the
menstrual cycle.
• Please read thoroughly.
• Discussion summary related to other
hormones will be posted later.
• Reference
• Principles of anatomy and physiology. Tortora
and Derrickson, 13 ed
• Case-files-physiology, McGraw – Lange, 2nd
edition.