True hyperprolactinemia in men without visible pituitary adenoma

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madman

Super Moderator
Abstract

Purpose
Men with mild to moderate hyperprolactinemia rarely present with normal pituitary on MRI with no visible adenoma, a condition entitled also “idiopathic hyperprolactinemia” or “non-tumoral hyperprolactinemia”. We have characterized a cohort of hyperprolactinemic men with normal pituitary imaging.

Design We have identified 13 men with true hyperprolactinemia and normal pituitary MRI. Baseline clinical and hormonal characteristics and response to medical treatment were retrospectively retrieved from medical records.

Results Mean age at diagnosis was 51 ± 16 years (range, 20–77); mean serum prolactin level at presentation was 91 ng/ml (range, 28–264), eight men presented with low baseline testosterone. Initial complaints leading to diagnosis included sexual dysfunction in ten men and gynecomastia in five. All patients were treated with cabergoline, except for one who was given bromocriptine; none required pituitary surgery. All patients normalized prolactin and testosterone with subsequent clinical improvement reported by most men. Currently, after a mean follow-up of 72 months, ten patients continue treatment with cabergoline (median weekly dose, 0.25 mg), whereas three men discontinued treatment.

Conclusions Men with symptomatic hyperprolactinemia may rarely present with normal pituitary imaging. Medical treatment can lead to hormonal improvement with clinical benefit.




Introduction

Prolactinomas, benign prolactin (PRL)-secreting tumors, are the most common functional pituitary adenomas, accounting for 60% of secreting pituitary tumors. Prolactinomas are subdivided into microprolactinomas (<10 mm) and macroprolactinomas (≥10 mm) based on their size at presentation [1]. In women, most prolactinomas (90%) are microadenomas [2], whereas males present with macroadenomas in 80–85% of the cases, many of them are very large and invasive [3]. Thus, microadenomas account for only 10–15% of all male prolactinomas [4]. Men with mild to moderate hyperprolactinemia may rarely present with normal pituitary MRI imaging and no visible adenoma, and this condition is also entitled “idiopathic hyperprolactinemia” or “non-tumoral hyperprolactinemia”. Drug-induced hyperprolactinemia, macroprolctinemia, chronic renal failure, and primary hypothyroidism must be excluded, and repeated prolactin measurement 2–3 h after waking up from sleep will establish this rare diagnostic entity of idiopathic hyperprolactinemia. These rare cases will usually imitate very small pituitary microprolactinomas (1–3 mm in diameter) not depicted by the 3-Tesla MRI systems currently in use, similarly to the far more frequent idiopathic hyperprolactinemia commonly encountered in hyperprolactinemic women [5].

Men with idiopathic hyperprolactinemia can present differently from males with micro- or macropaprolactinomas, but usually, respond to medical treatment with dopamine agonists, with suppression of PRL to normal and subsequent clinical improvement.

As idiopathic hyperprolactinemia is uncommon in men, we report our experience with the diagnosis and treatment of 13 male patients with true hyperprolactinemia and no visible pituitary adenoma on MRI.



*Prolactinomas in women and men respond to cabergoline, achieving PRL normalization in 85–95% of microprolactinomas, and 75–85% for macroprolactinomas [4, 13, 14]. In our cohort, all patients responded to cabergoline with PRL suppression to normal. This is in line with the trend of small prolactinomas to respond better to dopamine agonist treatment compared to macroadenomas or giant prolactinomas in men [15]. Moreover, the cabergoline dosage used was relatively low, and patients were continuously maintained and controlled with a median dose of 0.25 mg/week. However, men that discontinued dopamine agonist treatment-experienced a relapse of hyperprolactinemia.




In conclusion, men with symptoms of hypogonadism rarely present with hyperprolactinemia without visible pituitary adenoma. This true hyperprolactinemia, albeit mild responds to treatment with dopamine agonists together with subsequent clinical improvement in most men, thus highlights the benefits patients with such a rare condition may obtain.
 

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madman

Super Moderator
Table 1 Baseline characteristics of 13 men with true hyperprolactinemia and normal sellar imaging
Screenshot (3653).png
 

madman

Super Moderator
Table 2 osteopenia in one and osteoporosis in one. The man with Baseline characteristics and response to medical treatment of each patient in the cohort
Screenshot (3654).png
 

madman

Super Moderator
Fig. 1 Baseline and current testosterone (ng/ml; normal, 2.8–9; lower normal limit highlighted by the dashed line) following medical treatment, and clinical response. + clinical response, − no clinical response, N/A clinical information is not available
Screenshot (3655).png
 

MDavidW76

Active Member
Last year my TT was 131ng/dl, my prolactin was
14.12 ng/mL in a range of 2.64-13.13 ng/mL. My old TRT doctor simply asked if I was ever checked for a pituitary tumor, my reply was no I had not. I’m wondering if I should get my Prolactin level checked again?
 

JmarkH

Well-Known Member
Had an MRI last Monday, turns out I have a pituitary tumor
The following isn't intended to cause even more anxiety, but to hopefully facilitate finding the best protocol for your situation.
My father developed a pituitary tumor in the mid-nineties. At that time, the prevailing treatment was high estrogen of some sort. He had a multitude of side effects from this, many of which the doctor warned him about. I'm sure it also crashed what little testosterone he had. It did shrink the tumor. A few years later he developed prostate cancer. After twelve years, cancer took his life.
From what I now know, I would've pushed him to seek advice from several more specialists. I would hope today, that treatment is more advanced.
You're in my thoughts and prayers. Please keep us updated.
 

Nelson Vergel

Founder, ExcelMale.com
View attachment 21637Had an MRI last Monday, turns out I have a pituitary tumor
Sorry to hear. Most are treatable or cause no harm. I am surprised since your prolactin wasn't bad.

You may want to read these:






 

MDavidW76

Active Member
@Nelson Vergel
Table 1 in the first link PRL - secreted at stressful times - oh boy, the last week is killing me… daughter attempting to OD on Aspirin, very stressful. I can say if it wasn’t for me taking P5P daily I’d probably have a great set of DD moobs with all the stress we’re going through. My GP wants to discuss how to tackle this. I’m also looking at a 3 month recovery in my near future as my neurosurgeon wants to give me microdiscectomy sometime soon. I’m falling apart.
 

Nelson Vergel

Founder, ExcelMale.com
I am so sorry to hear about your stress. My two super successful twin sisters with kids committed suicide (bipolar disorder), so I know how that can affect your world. Make sure your daughter gets counseling and a diagnosis if she does not have one.

I would not consider surgery for such small adenoma with such low production of prolactin. Studies have shown most are benign and respond well to cabergoline (assuming they are prolactinomas).

I would get your PCP to test for all of these hormones:

pituitary tumors.gif
 
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