Editorial: Is macroprolactinemia just a diagnostic pitfall?

Bronstein, Marcello D.

doi:10.1007/s12020-012-9608-0

Cited by 13 publications

(7 citation statements)

References 12 publications

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“…It has been mostly suspected when hyperprolactinemic patients do not present the typical symptoms and/or evidence of a pituitary tumor on magnetic resonance imaging (MRI) (15,21,44,60,65,66). However, many patients with macroprolactinemia can have nonspecific symptoms, and neuroradiological abnormalities are also frequent (see below) (44,59,65).…”

Section: Clinical Relevancementioning

confidence: 99%

Challenges and pitfalls in the diagnosis of hyperprolactinemia

Vilar

Fleseriu

Bronstein

2014

Arq Bras Endocrinol Metab

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112

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The definition of the etiology of hyperprolactinemia often represents a great challenge and an accurate diagnosis is paramount before treatment. Although prolactin levels > 200-250 ng/mL are highly suggestive of prolactinomas, they can occasionally be found in other conditions. Moreover, as much as 25% of patients with microprolactinomas may present prolactin levels < 100 ng/mL, which are found in most patients with pseudoprolactinomas, drug-induced hyperprolactinemia, or systemic diseases. On the other hand, some conditions may lead to falsely low PRL levels, particularly the so-called hook effect, that is an assay artifact caused by an extremely high level of PRL, and can be confirmed by repeating assay after a 1:100 serum sample dilution. The hook effect must be considered in all patients with large pituitary adenomas and PRL levels within the normal range or only modestly elevated (e.g., < 200 ng/mL). An overlooked hook effect may lead to incorrect diagnosis and unnecessary surgical intervention in patients with prolactinomas. Another important challenge is macroprolactinemia, a common finding that needs to be identified, as it usually requires no treatment. Although most macroprolactinemic patients are asymptomatic, many of them may present galactorrhea or menstrual disorders, as well as neuroradiological abnormalities, due to the concomitance of other diseases. Finally, physicians should be aware that pituitary incidentalomas are found in at least 10% of adult population. Arq Bras Endocrinol Metab. 2014;58(1):9-22 Keywords Hyperprolactinemia; diagnostic pitfalls; hook effect; macroprolactinemia; pituitary incidentalomas RESUMO A definição da etiologia da hiperprolactinemia muitas vezes representa um grande desafio e um diagnóstico preciso é fundamental antes do tratamento. Embora níveis de prolactina > 200-250 ng/mL sejam altamente sugestivos de prolactinomas, ocasionalmente podem ser encontrados em outras condições. Além disso, até 25% dos pacientes com microprolactinomas podem apresentar-se com níveis de prolactina < 100 ng/mL, os quais são evidenciados na maioria dos pacientes com pseudoprolactinomas, hiperprolactinemia induzida por drogas ou doenças sistêmicas. Por outro lado, deve--se atentar às condições que podem levar a valores de prolactina falsamente baixos, particularmente o chamado efeito gancho. Este último é um artefato causado por um nível extremamente elevado de PRL e que pode ser confirmado pela repetição do exame após diluição do soro a 1:100. O efeito gancho deve ser considerado em todo paciente com grandes adenomas hipofisários e níveis de prolactina dentro da faixa normal ou apenas moderadamente elevados (p. ex., < 200 ng/mL). Um efeito gancho não detectado pode levar a diagnóstico incorreto e intervenção cirúrgica desnecessária em pacientes com prolactinomas. Outro desafio importante é a macroprolactinemia, um achado comum que precisa ser identificado visto que geralmente não requer tratamento. Ainda que a maioria dos pacientes seja assintomática devido à concomitância de outr...

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Section: Clinical Relevancementioning

confidence: 99%

Challenges and pitfalls in the diagnosis of hyperprolactinemia

Vilar

Fleseriu

Bronstein

2014

Arq Bras Endocrinol Metab

Self Cite

112

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“…Consisting mainly from complexes of prolactin with IgG, macroprolactin may be also composed of complexes formed by prolactin and IgA or IgM, or aggregates of covalent or non-covalent polymers of monomeric prolactin [ 13 – 15 ]. The term “macroprolactinemia” is used when macroprolactin content exceeds 60 % of the total circulating levels determined by polyethylene glycol precipitation [ 16 , 17 ]. Although most subjects are asymptomatic, in the remaining ones, macroprolactinemia may result in galactorrhea, oligomenorrhea/amenorrhea, subfertility/infertility, and gynecomastia [ 18 – 20 ].…”

Section: Introductionmentioning

confidence: 99%

Sexual function and depressive symptoms in young women with elevated macroprolactin content: a pilot study

2016

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Elevated prolactin levels seem to be associated with impaired sexuality. The clinical significance of macroprolactinemia, associated with the predominance of high molecular mass circulating forms of prolactin, is still poorly understood. This study was aimed at investigating sexual function in young women with macroprolactinemia. The study enrolled 14 young women with macroprolactinemia, 14 with increased monomeric prolactin levels, as well as 14 age- and weight-matched healthy women. All patients completed a questionnaire evaluating female sexual function (Female Sexual Function Index—FSFI), as well as a questionnaire assessing the presence and severity of depressive symptoms (Beck Depression Inventory Second Edition—BDI-II). Apart from total prolactin levels and macroprolactin content, circulating levels of thyrotropin, total testosterone, and 17-β estradiol were also measured. Patients with elevated monomeric prolactin levels had a lower total FSFI score, as well as lower scores for all domains: sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction, and dyspareunia. These scores correlated with total and monomeric prolactin levels. In turn, women with macroprolactinemia were characterized by a lower score for sexual desire, and only this score correlated with total prolactin levels and macroprolactin content. The total score in the BDI-II questionnaire was higher in patients with hyper- and macroprolactinemia than in the control subjects. Contrary to multidimensional impairment of sexual function in women with elevated monomeric prolactin, macroprolactinemia only seems to disturb sexual desire.

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“…In most of the in vitro studies, macroprolactin was shown to display low biological activity (28,29,55). This is corroborated by the finding that in most series with macroprolactinemia, individuals are pauci-or asymptomatic (56,57), with no need to perform sellar imaging (58) or specific treatments (58,59). Others argued that the binding of PRL to their receptor could The hook effect differs between the different assay systems used in clinical practice.…”

Section: Macroprolactinemia Screening: Routinely or Just In Asymptomamentioning

confidence: 96%

“…However, there are individuals who, despite increased macroprolactin, also present with high levels of monomeric PRL, leading to "true" hyperprolactinemia with clinical symptoms and the need foran etiologic diagnosis for the proper management of hyperprolactinemia (59). Moreover, the presence of symptoms could result from the concomitance of macroprolactinemia with other conditions, such as polycystic ovary syndrome (61), idiopathic galactorrhea (1,2), or psychogenic erectile dysfunction (62).…”

Section: Macroprolactinemia Screening: Routinely or Just In Asymptomamentioning

confidence: 99%

Controversial issues in the management of hyperprolactinemia and prolactinomas – An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

Vilar¹,

Abucham²,

Albuquerque³

et al. 2018

Archives of Endocrinology and Metabolism

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Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.

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Editorial: Is macroprolactinemia just a diagnostic pitfall?

Cited by 13 publications

References 12 publications

Challenges and pitfalls in the diagnosis of hyperprolactinemia

Challenges and pitfalls in the diagnosis of hyperprolactinemia

Sexual function and depressive symptoms in young women with elevated macroprolactin content: a pilot study

Controversial issues in the management of hyperprolactinemia and prolactinomas – An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

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