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A Current Approach to Hyperprolactinemia

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A Current Approach to Hyperprolactinemia ISSN: 2572-407X Lau and Aw. Int Arch Endocrinol Clin Res 2019, 5:018 DOI: 10.23937/2572-407X.1510018 Volume 5 | Issue 1 International Archives of Open Access Endocrinology Clinical Research REVIEW ARTICLE A Current Approach to Hyperprolactinemia Lau CS1 and Aw TC1,2* Check for 1Department of Laboratory Medicine, Changi General Hospital, Singapore updates 2Department of Medicine, National University of Singapore, Singapore *Corresponding author: Tar Choon Aw, Department of Laboratory Medicine, Changi General Hospital, Simei Street 3, 529889, Singapore, Tel: +65-68504927, Fax: +65-64269507, E-mail: [email protected] Abstract Introduction Prolactin is a hormone secreted by the anterior pituitary Prolactin (PRL) is a hormone synthesized and se- lactotrophs and is controlled by the influence of hypotha- creted by the anterior pituitary lactotrophs. This pro- lamic dopamine. PRL stimulates the proliferation and dif- cess is influenced by multiple stimulatory and inhibi- ferentiation of mammary cells for lactation. There are tory factors, the chief of which is dopamine [1]. Nor- many causes for hyperprolactinemia, including analytical, physiological, pharmacological, pathological and idiopath- mally, dopamine from the hypothalamic arcuate nu- ic causes. Macroprolactin is a significant analytical cause cleus acts on specific lactotroph dopamine receptors of hyperprolactinemia, and the most common cause of (D2) and inhibits pituitary PRL secretion [2]. The D2 pathological hyperprolactinemia is prolactin secreting ade- receptor gene is located on chromosome 11. PRL is nomas. Symptoms of true hyperprolactinemia include ga- encoded by a single gene, located on chromosome 6 lactorrhoea, secondary amenorrhea, oligomenorrhea and hypogonadotropic hypogonadism. Larger macroadenomas in humans [3]. Following its production pre-PRL (227 can cause compressive symptoms on the pituitary gland or amino acids) is cleaved to form PRL (199 amino ac- visual symptoms. A single measurement of serum PRL ob- ids), a 23 kDa protein [4]. Extra-pituitary PRL has also tained at any time of the day can be used to diagnose hy- been reported. Pituitary and extra-pituitary PRL have perprolactinemia. Macroprolactinemia should be excluded in all cases of hyperprolactinemia, and polyethylene glycol identical structures and bind PRL-R but the mecha- precipitation is a fast, convenient and inexpensive method nisms of their regulation differ and are being eluci- to exclude macroprolactinemia. Other interferents that can dated [5]. Prolactin has strong structural homology cause falsely low prolactin readings include the hook effect, with growth hormone and placental lactogen [6]. PRL biotin and heterophilic antibodies. Physicians must know is involved in the control of lactation. Post-partum, how to approach hyperPRL and exclude the most important differential diagnoses of prolactinomas. PRL stimulates the differentiation and proliferation on mammary cells that has been primed for lactation Keywords by other hormones - estrogen, progesterone, insulin, Prolactin, Hyperprolactinemia, Macroprolactinemia, Prolac- corticosteroids and Growth Hormone (GH). The large tinomas, PEG increase in PRL during lactation is associated with a Abbreviations decreased dopamine output, mediated by a decrease in the phosphorylation of tyrosine hydroxylase, the PRL: Prolactin; PRL-R: Prolactin Receptor; MacroPRL: rate-limiting enzyme in dopamine synthesis [7]. Macroprolactin; HyperPRL: Hyperprolactinemia; CKD: Chronic Kidney Disease; Prolactinomas: Prolactin- During lactation, the increase in PRL is accompanied secreting Adenoma; PEG: Polyethylene Glycol; FSH: by the proliferation and hypertrophy of lactotrophs Follicle Stimulating Hormone; LH: Luteinizing Hormone; in the pituitary gland [8]. Even after lactation with AMH: Anti-Mullerian Hormone a return of dopamine inhibition, the hypertrophy of the lactotrophs persists for several months, allowing for higher PRL levels with subsequent lactation [2]. Citation: Lau CS, Aw TC (2019) A Current Approach to Hyperprolactinemia. Int Arch Endocrinol Clin Res 5:018. doi.org/10.23937/2572-407X.1510018 Accepted: December 02, 2019: Published: December 04, 2019 Copyright: © 2019 Lau CS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Lau and Aw. Int Arch Endocrinol Clin Res 2019, 5:018 • Page 1 of 8 • DOI: 10.23937/2572-407X.1510018 ISSN: 2572-407X Besides the 23 kDa PRL monomer (‘little PRL’) other ed reagents are washed away. The signal generated PRL isoforms are present in the circulation. These mac- is directly proportional to the sample prolactin con- ro-molecular complexes of PRL and IgG autoantibodies centration. These modern immunometric assays are are ‘big PRL’ (48-56 kDa) and ‘big big PRL’ (> 150 kDa), a free from cross-reactivity of related molecules such polymer referred to as macroprolactin (macro-PRL) [9]. as growth hormone and placental lactogen. Interfer- In normal subjects, total circulating prolactin compris- ence from heterophilic antibodies are also very rare- es 65-85% little PRL, 10-20% big prolactin, and < 10% ly encountered as such assays have been optimised big big prolactin [10]. Macro-PRL has minimal biological with blocking agents. However, interference from activity and pathological function but is variably detect- macro-PRL remains common. Most of the PRL assays ed in the current PRL immunoassays. The large size of are standardised to the World Health Organisation’s macroPRL results in lower renal clearance and this el- third international prolactin standard 84/500, which evates the total PRL without any increase in lactotroph consists of the 23 kDa little PRL derived from human PRL release. This phenomenon, also called “analytical pituitaries. However, despite general concordance hyperprolactinemia”, can lead to misinterpretation of between PRL methods, agreement of PRL results PRL results. Proteolytic cleavage of the active 23kDa from different vendors is still poor and PRL reference PRL protein produces 14kDa, 16kDa and 22kDa PRL vari- intervals are platform specific. The expected serum ants [4]. There has been increasing interest in the role of PRL concentration in normal adult males and females the 16kDa fragment of prolactin in angiogenesis. It uses is less than 14 ug/L and 24 ug/L respectively (PRL con- plasminogen activator inhibitor-1 as a binding partner version units: I ug/L = 21.2 mU/L). The reported ref- to activate the urokinase-type plasminogen activator erence ranges for total PRL on the Abbott Architect receptor [11,12] which inhibits angiogenesis [13]. This assay is 2.7-19.7 ug/L for males and 3.0-26.4 ug/L for 16kDa PRL variant may have roles in peripartum cardio- females [24]. Serum PRL is unaffected by food and a myopathy [14] and preeclampsia [15]. fasting sample is not necessary [25]. PRL acts via its membrane receptor, the Prolactin Causes of Hyperprolactinemia Receptor (PRL-R), the gene for which is located on chro- mosome 5 [16]. PRL-R (598 amino acids) is formed from The causes of hyperprolactinemia (hyperPRL) are the cleavage of pre-PRL-R (622 amino acids). PRL-R is a listed in Table 1. The prevalence of hyperPRL is about member of the class 1 hematopoietic cytokine recep- 10 per 100,000 in men and 30 per 100,000 in women, tor superfamily that includes GH [17]. The structure of respectively and it is the second most common cause of the PRL-R has now been elucidated and the mechanism infertility in women after Polycystic Ovarian Syndrome of its activation deciphered [2]. Human PRL-R binds 3 (PCOS) [25]. ligands (PRL, GH, and placental lactogen) rendering it Causes of Hyperprolactinemia. difficult to ascertain the specific effects of PRL in vivo Table 1: [18]. The PRL-R, initially thought to be restricted to lac- 1. Analytical (e.g. Macroprolactinemia) tating cells, has been now found to be widespread in the 2. Physiological body including in adipose tissue, skin and hair follicles, a. Pregnancy pancreas, bone and adrenal glands [19]. In the pancre- b. Lactation as, it regulates the ontogenesis of pancreatic stem cells to create a functional reserve of beta cells [20] that may c. Stress contribute to beta-cell proliferation during pregnancy. 3. Pharmacological The pituitary gland is an anatomic meshwork of dif- a. Anti-psychotics (e.g. risperidone) ferentiated cells with great plasticity that enables for- b. Anti-hypertensives (e.g. verapamil) mation of new differentiated cell types in response to c. Anti-depressants (e.g. tricyclic antidepressants) new signals and inputs [21]. Control of pituitary function d. Anti-epileptic drugs is complex and finely integrated through three tiered e. Metoclopramide loops - the hypothalamus, intrapituitary signals, and pe- f. Opiates ripheral hormone feedback [22]. This complex regula- tion results in production of sufficiently abundant and g. Estrogens (e.g. oral contraceptives) appropriately timed regulatory secretions in response 4. Pathological to external cues [23]. a. PRL secreting adenomas Measurement of Serum Prolactin b. Hypothalamic/pituitary stalk disorders (e.g. granulo- matous disease, irridation, trauma) Current automated immunoassays employed in c. Renal dysfunction clinical laboratories use a two-site immunometric or d. Hepatic failure sandwich assay principle. Prolactin in the sample re- e. Hypothyroidism acts with a capture antibody immobilised on
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