Hyperprolactinemia

Hyperprolactinemia affects up to 1 in 10 people, making it one of the most common hormone disorders of the pituitary gland. High prolactin levels can lead to fertility problems, irregular menstrual cycles, decreased sex drive, and other reproductive health concerns. The good news is that with proper diagnosis and management, most people with hyperprolactinemia can manage their symptoms effectively and restore their reproductive health. 

What is Hyperprolactinemia? 

Hyperprolactinemia is a medical condition characterised by higher-than-normal levels of prolactin in the blood. This hormone is exclusively produced by the anterior pituitary gland, a pea-sized organ situated at the base of the brain. 

This condition is diagnosed when prolactin levels exceed the normal range. Medical laboratories typically consider the following values as normal: 

• For men: Less than 20 ng/mL 
• For non-pregnant women: Less than 25 ng/mL 
• For pregnant or breastfeeding women: 80 to 400 ng/mL 

The human body maintains a careful balance of prolactin, metabolising the hormone primarily by the liver (75%) and kidneys (25%). Under normal circumstances, prolactin has a half-life of 25 to 50 minutes in the bloodstream, with a secretion rate of 200 to 536 mcg per day per square metre of body surface. 

What is Prolactin? 

Prolactin is a vital hormone produced primarily by the anterior pituitary gland, with additional production occurring in various body tissues, including the central nervous system, immune system, uterus, and mammary glands. This complex hormone belongs to the same family as growth hormone and placental lactogen, sharing a similar chemical structure. 

The hormone serves multiple essential biological functions in the body: 

• Initiates and maintains lactation 
• Supports breast tissue development 
• Aids in pregnancy implantation 
• Promotes mammary gland cell growth 
• Contributes to immune system regulation 
• Assists in blood vessel formation 

The production and release of prolactin are carefully controlled by two main factors: dopamine, which inhibits its release, and oestrogen, which stimulates it. Various stimuli can trigger prolactin production, including nipple stimulation, stress, and certain medications like antipsychotics. 

Prolactin works by binding to specific receptors found throughout the body, including the ovaries, uterus, breasts, liver, and brain. These receptors, known as prolactin receptors (PRL-Rs), translate the hormone's signals into biological actions through various cellular pathways. 

Hyperprolactinemia Symptoms 

The following are some common high prolactin levels symptoms: 

• Infertility 
• Decreased libido (sexual desire) 
• Reduced bone mass 
• Milky discharge from nipples (galactorrhea) 

Women with hyperprolactinemia often experience menstrual irregularities, including irregular periods or complete absence of menstruation (amenorrhea). They may also notice vaginal dryness, which can lead to discomfort during intimate relations. 

Males with elevated prolactin levels typically experience different symptoms. These include erectile dysfunction, decreased testosterone hormone levels, and the development of enlarged breast tissue, a condition known as gynecomastia. 

Causes and Risk Factors of Hyperprolactinemia 

Doctors categorise these causes into three main types: physiological, pathological, and medication-related. 

• Physiological Causes of Hyperprolactinemia: Various health conditions can result in elevated prolactin levels: 
  • Prolactinoma (The most common cause) is a benign tumour that develops in the pituitary gland. These tumours occur more frequently in females than males. 
  • Chronic kidney disease 
  • Underactive thyroid (hypothyroidism) 
  • Shingles affecting the chest area 
  • Polycystic ovary syndrome 
  • Chest wall injuries 
  • Other pituitary gland tumours 
• Medication-related Causes of Hyperprolactinemia: Certain medicines that affect dopamine levels in the body can trigger high prolactin levels: 
  • Antipsychotic medications (particularly risperidone) 
  • Anti-nausea medications 
  • Birth control pills 
  • High blood pressure medications 
  • Medications for heartburn and gastrointestinal reflux disease (GERD) 
  • Pain medications containing opioids  
  • Some antidepressants 
• Psychological Causes of Hyperprolactinemia: Physical and psychological factors that may cause temporary increases in prolactin levels are: 
  • Stress 
  • Exercise 
  • Chest wall stimulation 
  • Pregnancy (prolactin levels naturally rise, with the pituitary gland increasing in size and prolactin levels reaching their peak at delivery) 

Complications of Hyperprolactinemia 

The condition primarily affects reproductive health in several ways: 

• Persistent infertility due to disrupted ovulation in women 
• Reduced bone density leading to osteoporosis 
• Decreased testosterone production in men 
• Impaired sexual function in both sexes 
• Interference with the normal menstrual cycle 
• Preventing successful embryo implantation 

Additional complications may develop when hyperprolactinemia occurs due to a pituitary tumour (prolactinoma). These include mass effect complications such as: 

• Visual deficits 
• Cranial nerve problems 
• Pituitary apoplexy (sudden bleeding into the tumour) 
• Psychosis, particularly when prolactin levels remain high for extended periods 

Diagnosis 

The initial blood test serves as a starting point, but this test cannot identify the underlying cause of high prolactin levels. Doctors consider several factors when interpreting test results: 

• Thyroid function tests 
• Kidney function assessment 
• Hormone level measurements 
• Pregnancy testing (for women of childbearing age) 
• Growth factor analysis 

If blood tests confirm hyperprolactinemia, doctors often recommend magnetic resonance imaging (MRI) of the brain. This detailed scan helps identify potential tumours in the pituitary gland, particularly prolactinomas, which can cause elevated prolactin levels. 

Treatment 

Doctors generally recommend the following treatment options: 

• Dopamine Agonists: These medications are the first-line treatment. They work by mimicking dopamine's natural ability to reduce prolactin production. 
• Hormone Replacement: Some patients may receive oestrogen or testosterone therapy to address specific symptoms 
• Surgery: Reserved for cases where medications prove ineffective, or tumours threaten vision 
• Radiation Therapy: A rare option used when both medication and surgery have not provided adequate results 
• Medication Management: Doctors may prescribe another similar type of medicine to prevent hyperprolactinemia if prescription medications are causing it. 

When to See a Doctor 

Immediate medical guidance is necessary in these situations: 

• Development of new or worsening headaches 
• Changes in vision or visual field defects 
• Unexpected breast milk production 
• Significant menstrual changes New or worsening fertility issues 

Prevention 

Several lifestyle modifications can help maintain healthy prolactin levels: 

• Practise stress management through meditation and deep breathing 
• Maintain consistent sleep patterns and good sleep hygiene 
• Consume a balanced diet rich in vitamin B6, zinc, and magnesium 
• Engage in moderate regular exercise without overexertion 
• Maintain a healthy weight through proper nutrition 
• Limit alcohol and caffeine consumption 
• Avoid wearing restrictive clothing around the chest area 
• Genetic Testing: This may help detect a prolactinoma at an early stage if you have a first-degree relative (sibling or parent) who has the condition. 

Conclusion 

The combination of medical treatment, lifestyle modifications, and regular monitoring helps patients achieve optimal outcomes. Regular check-ups, proper stress management, and healthy lifestyle choices play vital roles in managing prolactin levels effectively. These strategies, along with increasing awareness about the condition, continue to improve the quality of life for people affected by hyperprolactinemia. 

FAQS 

1. Who does hyperprolactinemia affect? 

Hyperprolactinemia primarily affects people under age 40, with women experiencing it more frequently than men. The condition rarely occurs in children, though it can affect people of any age or gender. 

2. How common is hyperprolactinemia? 

The condition affects less than 1% of the general population. In women with reproductive issues, the prevalence increases to 5-14% of cases, particularly in those experiencing irregular menstrual cycles. 

3. What is the difference between hyperprolactinemia and prolactinoma? 

While hyperprolactinemia refers to high prolactin levels from any cause, a prolactinoma is specifically a benign tumour that produces excess prolactin. Prolactinomas account for about 40% of all diagnosed pituitary tumours. 

4. What causes high prolactin levels in females? 

Several factors can raise prolactin levels in females: 

• Pregnancy and breastfeeding 
• Certain medications 
• Stress and physical exertion 
• Thyroid disorders 
• Chest wall injuries or stimulation 

5. What should I avoid if my prolactin is high? 

Individuals with high prolactin should avoid: 

• High-intensity workouts 
• Tight-fitting clothing around the chest 
• Excessive alcohol consumption 
• Foods high in sugar 
• Gluten-containing products 

6. Can high prolactin be serious? 

Yes, untreated high prolactin levels can lead to significant complications, including infertility, bone loss, and vision problems if caused by a large tumour. Regular monitoring and proper treatment help prevent these serious outcomes. 

7. Which foods reduce prolactin? 

While no specific foods directly lower prolactin, a balanced diet supporting overall hormonal health is beneficial. Include foods enriched in vitamin B6 and vitamin E, which may help maintain healthy prolactin levels. 

8. How is hyperprolactinemia tested for?

Testing involves a simple blood test measuring prolactin concentration, typically performed in the morning. Additional tests may include thyroid function assessment and MRI scans if a tumour is suspected.

Dr. Neha V Bhargava

MS, DNB (obgyn), MNAMS, Fellow (Gynae Oncology)
Ganga CARE Hospital Limited, Nagpur

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