An unusual case of galactorrhea in a postmenopausal woman complicating breast reduction

Galactorrhea is a relatively common condition, but has rarely been seen following breast reduction surgery. To date there are only seven cases reported in the literature, all in premenopausal women. Postsurgical galactorrhea is a diagnosis of exclusion and differential diagnosis is extensive. Common causes should be excluded first. We present the case of a 56-year-old postmenopausal woman who underwent bilateral breast reduction and developed galactorrhea 2 months postoperatively. MRI scan of the skull as well as Thyroid-Stimulating Hormone (TSH), prolactin levels were normal. She was on long-term hormonal replacement therapy. Because of suspected nerve-related pain in her right breast she was commenced on amitriptyline. We hypothesise that galactorrhea may have been caused by underlying neuroma or irritation of the anterior branch of the T4 intercostal nerve or hormonal replacement therapy or a combination of both.

Pituitary Macroadenoma Presenting As A Nasal Tumor: Case Report.

Pituitary macroadenomas are rare intracranial tumors. In a few cases, they may present aggressive behavior and invade the sphenoid sinus and nasal cavity, causing unusual symptoms. In this paper, we report an atypical case of pituitary adenoma presenting as a nasal mass. The patient was a 44-year-old woman who had had amenorrhea and galactorrhea for ten months, with associated nasal obstruction, macroglossia and acromegaly. Both growth hormone and prolactin levels were increased. Magnetic resonance imaging showed a large mass originating from the lower surface of the pituitary gland, associated with sella turcica erosion and tumor extension through the sphenoid sinus and nasal cavity. Histopathological analysis demonstrated a chromophobe pituitary adenoma with densely packed rounded epithelial cells, with some atypias and rare mitotic figures. There was no evidence of metastases. Macroadenoma invading the nasal cavity is a rare condition and few similar cases have been reported in the literature. This study contributes towards showing that tumor extension to the sphenoid sinus and nasopharynx needs to be considered and investigated in order to make an early diagnosis when atypical symptoms like nasal obstruction are present.

Management of prolactinomas in Brazil: an electronic survey

Dopamine agonists are the treatment of choice for prolactinomas. However, there are still controversies concerning dose, treatment duration and criteria for drug withdrawal in different clinical situations. The aim of this study was to assess diagnostic and therapeutic approaches to prolactinomas among members of the Brazilian Society of Endocrinology and Metabolism (SBEM). SBEM members answered a questionnaire sent by e-mail that included 18 questions related to controversial issues about the management of prolactinomas. Among SBEM members, 721 (approximately 24% of total) answered the questionnaire. Concerning the diagnosis, 38% of the respondents stated that prolactin levels < 100 ng/ml would exclude the presence of a prolactinoma. Most of them favored the screening for macroprolactin in asymptomatic individuals instead of a routine screening (74% vs. 26%). Regarding the treatment, 70% of the respondents chose cabergoline as the drug of choice to treat macroprolactinomas whereas similar proportions advised cabergoline or bromocriptine as the best treatment for microprolactinomas (52% vs. 48%). Only 20% and 34% of respondents favored treatment withdrawal 2-3 years after prolactin normalization in patients with macroprolactinomas and microprolactinomas, respectively. In case of pregnancy, only 58 and 70% of respondents advocated discontinuation of treatment with dopamine agonists in patients with macroprolactinomas and microprolactinomas, respectively. Finally, only 36% would allow breast-feeding without restriction, 44% would restrict it to patients with microprolactinomas and 20% would not recommend it for women with prolactinomas There are several points of disagreement among SBEM members regarding the management of prolactinomas.

Risperidone-induced symptomatic hyperprolactinaemia in adolescents.

Studies performed in adult patients unambiguously demonstrate a marked effect of risperidone on prolactin blood levels, with possible clinical effects related to hyperprolactinemia, such as gynecomastia and galactorrhea. However, the largest study performed in children and adolescents showed a weak effect of risperidone on prolactin concentrations during short-term treatment and a negligible effect during long-term treatment, which was probably because of the relatively low dosages of risperidone used [approximately 0.04 mg/(kg x d)]. Among the 10 psychotic adolescents treated with risperidone in our unit, we had 3 cases of gynecomastia in 3 male patients and 2 cases of galactorrhea in 2 female patients. The prolactin blood levels in these cases and in 3 other patients without apparent prolactin-related side effects were all above the normal range (median, 59 ng/mL; range, 30-123 ng/mL). Thus, risperidone administered to adolescents at doses commonly used for the treatment of psychotic symptoms can strongly increase prolactin levels, with clinical consequences such as gynecomastia and/or galactorrhea. Given that the long-term effects of antipsychotic drug-induced hyperprolactinemia are not well documented, especially regarding osteopenia, infertility, growth, and pubertal delay, risperidone should be administered with caution to children and adolescents.

Age and adverse drug reactions from psychopharmacological treatment: data from the AMSP drug surveillance programme in Switzerland.

QUESTION UNDER STUDY: The frequency of severe adverse drug reactions (ADRs) from psychotropic drugs was investigated in hospitalised psychiatric patients in relation to their age. Specifically, the incidence of ADRs in patients up to 60 years was compared to that of patients older than 60 years. METHODS: Prescription rates of psychotropic drugs and reports of severe ADRs were collected in psychiatric hospitals in Switzerland between 2001 and 2010. The data stem from the drug surveillance programme AMSP. RESULTS: A total of 699 patients exhibited severe ADRs: 517 out of 28,282 patients up to 60 years (1.8%); 182 out of 11,446 elderly patients (1.6%, ns). Logistic regression analyses showed a significantly negative relationship between the incidence of ADRs and patients' age in general and in particular for weight gain, extrapyramidal motor system (EPMS) symptoms, increased liver enzymes and galactorrhoea. A significantly negative relationship was observed for age and the dosages of olanzapine, quetiapine, risperidone, valproic acid and lamotrigine. When comparing age groups, frequency of ADRs was lower in general for antipsychotic drugs and anticonvulsants, in particular for valproic acid in the elderly. Weight gain was found to be lower in the elderly for antipsychotic drugs, in particular for olanzapine. For the group of mood-stabilising anticonvulsants (carbamazepine, lamotrigine and valproic acid) the elderly exhibited a lower incidence of reported allergic skin reactions. CONCLUSION: The results suggest that for psychiatric inpatients the incidence of common severe ADRs (e.g., weight gain or EPMS symptoms) arising from psychotropic medication decreases with the age of patients.

Clinical consequences of switching from olanzapine to risperidone and vice versa in outpatients with schizophrenia: 36-month results from the worldwide schizophrenia outpatients health outcomes (W-SOHO) study

BACKGROUND: With many atypical antipsychotics now available in the market, it has become a common clinical practice to switch between atypical agents as a means of achieving the best clinical outcomes. This study aimed to examine the impact of switching from olanzapine to risperidone and vice versa on clinical status and tolerability outcomes in outpatients with schizophrenia in a naturalistic setting. METHODS: W-SOHO was a 3-year observational study that involved over 17,000 outpatients with schizophrenia from 37 countries worldwide. The present post hoc study focused on the subgroup of patients who started taking olanzapine at baseline and subsequently made the first switch to risperidone (n=162) and vice versa (n=136). Clinical status was assessed at the visit when the first switch was made (i.e. before switching) and after switching. Logistic regression models examined the impact of medication switch on tolerability outcomes, and linear regression models assessed the association between medication switch and change in the Clinical Global Impression-Schizophrenia (CGI-SCH) overall score or change in weight. In addition, Kaplan-Meier survival curves and Cox-proportional hazards models were used to analyze the time to medication switch as well as time to relapse (symptom worsening as assessed by the CGI-SCH scale or hospitalization). RESULTS: 48% and 39% of patients switching to olanzapine and risperidone, respectively, remained on the medication without further switches (p=0.019). Patients switching to olanzapine were significantly less likely to experience relapse (hazard ratio: 3.43, 95% CI: 1.43, 8.26), extrapyramidal symptoms (odds ratio [OR]: 4.02, 95% CI: 1.49, 10.89) and amenorrhea/galactorrhea (OR: 8.99, 95% CI: 2.30, 35.13). No significant difference in weight change was, however, found between the two groups. While the CGI-SCH overall score improved in both groups after switching, there was a significantly greater change in those who switched to olanzapine (difference of 0.29 points, p=0.013). CONCLUSION: Our study showed that patients who switched from risperidone to olanzapine were likely to experience a more favorable treatment course than those who switched from olanzapine to risperidone. Given the nature of observational study design and small sample size, additional studies are warranted.

Estados hiperprolactinêmicos - Inter-relações com o psiquismo

Hyperprolactinemia is the most frequent endocrine disorder of the hypothalamus-hypophysis axis observed in women of reproductive age. It is characterized by elevated serum prolactin levels. Prolactin production is regulated by the inhibitory action of a neurotransmitter, dopamine. Clinical manifestations include irregular menstrual cycle, amenorrhea, galactorrhea, infertility and libido decrease, but psychological symptoms, especially anxiety and depression, have also been associated with hyperprolactinemia. Nonetheless, few studies about this condition are available. In the pathogenesis of psychiatric disorders, prolactin may have either a direct action on the central nerve system or an indirect effect via gonadal hormones or function as independent factors as a result of dopamine depletion. Thus, since the prevalence of psychiatric disorders in patients with hyperprolactinemia was detected, it was concluded that further studies are necessary to investigate the basis of a potential relationship between both hyperprolactinemic and psychiatric conditions.

Bromocriptine Treatment for Inappropriate Lactation in Mares: A Case Report

Transient mammary gland development and lactation can occur eventually in weanling foals, yearlings, and adult mares without previous or recent history of pregnancy. The etiology of this condition has not been well documented, and there is limited information on the occurrence, frequency of episodes, composition, and treatment of galactorrhea secretion. This article reports a case of Brazilian Sport Horse mare, aged 10 years, with persistent lactation during 5 months. The treatment consisted of bromocriptine 0.04 mg/kg, b.i.d., orally, for 10 days, associated with hydrotherapy for 20 minutes, twice daily. After 20 days of the treatment onset, the mare was reevaluated, and a significant decrease in the volume of the udder and the amount of secretion produced was noted, and its aspect was clearer (serous) and consisted of more fluid compared with the one collected before treatment. No other clinical alterations or associated diseases were identified. Based on these findings, we suggest the diagnosis of idiopathic inappropriate lactation. Although there is no information about pharmacokinetics and description of the oral bromocriptine use in horses, being a therapeutic option for inappropriate lactation treatment in mares, it was effective at the recommended dosage. (C) 2012 Elsevier Inc. All rights reserved.

Macroprolactinemia e hiperprolactinemia intermediária: manifestações clínicas e achados radiológicos

OBJETIVOS: Caracterizar as pacientes com valores indeterminados de hiperprolactinemia (teste de PEG para identificação de macroprolactinemias com recuperação entre 30 e 65%) (PRLi) ou macroprolactinemia (PRLm), quanto às características clínicas, como intensidade e variação dos sintomas e presença ou não de tumores no sistema nervoso central. MÉTODOS: Estudo transversal, retrospectivo, de levantamento de prontuários, no qual foram incluídas 24 pacientes com diagnóstico de hiperprolactinemia (PRL>25 ng/dL), em idade reprodutiva, em seguimento em ambulatório de ginecologia endócrina. Foram incluídas 11 pacientes com PRLm e 13 com PRLi. Dos dois grupos (PRLm e PRLi), foram considerados para a análise registros dos dados relativos à idade, à paridade, ao índice de massa corporal, à presença de galactorreia, à infertilidade e ao tumor do sistema nervoso central. Os dados antropométricos foram expressos em média e desvio padrão e, para a comparação entre os grupos quanto à presença de tumor no sistema nervoso central, galactorreia e infertilidade, utilizou-se o teste t de Student. RESULTADOS: A galactorreia foi mais prevalente nas pacientes com PRLi (p=0,01). Setenta por cento das mulheres com PRLi apresentaram microprolactinoma de hipófise, enquanto que este achado foi evidente em 17% das mulheres com PRLm (p=0,04). Dentre as pacientes com PRLm e PRLi, nove não foram investigadas com imagem do sistema nervoso central por apresentarem níveis pouco elevados de prolactina (cinco portadoras de PRLm e quatro de PRLi). Não houve diferença significativa quanto à ocorrência de infertilidade ou de ciclos menstruais irregulares. CONCLUSÕES: Mulheres com hiperprolactinemia intermediária apresentam mais sintomas de galactorreia e maior incidência de tumores do sistema nervoso central do que aquelas com macroprolactinemia.