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Prolactin in Plab
A concise intro
Secreted from : Lactotropes cells, in the anterior pituitary
Controlled by : Mainly by Dopamine from the hypothalamus which
reaches the anterior pituitary via stalk
Nature & function: Peptide hormone, Lactation
Ref range : 300-500 mU/l

Dopamine inhibit the secretion of prolactin

Here an important question which make you think about the

control of prolactin secretion. (please look at the picture above
and try to answer)
What happen to the secretion of prolactin if you severe (cut down) the stalk which connect pituitary to
hypothalamus? Think…...think….. think….before you can see the answer in the next page...

Hyperprolactinemia

Reminding some important clinical features of hyperprolactinemia

• Galactorrhoea in women and Gynecomastia in men
• Oligomenorrhoea or amenorrhoea and subfertility
• Decreased libido in both sexes and decreased potency in men
• osteoporosis long term complication
• delayed puberty

Listing some important causes of hyperprolactinemia

Physiological Pathological Drug-induced
Pregnancy, lactation, sleep, Prolactinoma, Stalk compression, OCP, Dopamine antagonist
exercise, coitus PCOD, Primary hypothyroidism, (Antipsychotics), TCA, SSRI ,
Liver failure mcqs Verapamil, Methyldopa mcqs

Now we discuss about some important causes of hyperprolactinemia.

1. Pregnancy
• If a young girl presents with galactorrhea, Never miss to exclude pregnancy. mcq
• During pregnancy and lactation prolactin level may reach 10,000 mU/l (300-500 mU/l)
2. Prolactinoma- Prolactin secreting adenoma
Here we use 3 important words (read those carefully)
1. Micro-prolactinoma 2. Macro-prolactinoma 3. Macro-prolactinemia
Micro-prolactinoma:
• Adenoma size < 1cm
• if prolactin levels between 3000-6000 mU/l due to micro-prolactinoma.
• However, if the levels are >1000mU/l, if there is no other obvious causes,(ex-hypothyroidism)
then choose micro-prolactinoma in the mcq

Macro-prolactinoma:
• Adenoma size>1cm
• if prolactin levels >6000 mU/l mostly due to macroprolacttinoma.

Pituitary adenoma Histological charcters

Prolactinoma Chromophobe adenoma
GH secreting adenoma Eosinophilic /acidophilic adenoma mcq
Corticotroph adenoma Basophilic adenoma

Diagnosis: 1. Hormone Assay (often levels are >1000mU/l in adenomas), 2.MRI pituitary- definitive

Treatment of prolactinoma
1. Treatment of both micro and macro-adenomas can be initiated with dopamine agonists: Cabegoline
superior to Bromocriptine mcq
2. If fails, treat trans-sphenoidal surgery.- Definitive treatment mcq
3. Radiotherapy also an option
Pituitary tumors with compression symptom- Always surgery is the choice mcq

Then, what is Macro-prolactinemia? mcq

• This is not related to pituitary pituitary adenoma.
• Prolactin circulates in 2 main forms.
1. Small Monomeric prolactin (biologically active), with a small molecular mass, usually
accounts for 85–95% of the prolactin present
2. Big prolactin species makes up <10% called Macro-prolactin (biologically inactive).

In some idividual, the majority of the prolactin is in macro form. So, the prolactin assays in these
ividuals shows very high prolactin levels even though these individual don’t develop any symptom
because macro-prolactins are biologically inactive.

Important point is: If you see an mcq which says patient is asymptomatic, but prolactin levels are
high, then, the answer is Macro-prolactinemia. mcq. No treatment needed for Macro-prolactinemia

3. Stalk compression
Here is the answer to the question in the previous page:
80% of pituitary adenomas are non functional ( don’t produce any hormone).mcq
However, this non functional adenomas sometimes can compress the stalk when it enlarges and cut
the dopamine access to the pituitary. So, no more dopamine inhibition for prolactin secretion. This
will eventually leads to hyperprolactinemia.
As you all know, Pitutary tumors can compress the Optic chiasma and can produce bitemporal-
hemianopia (peripheral vision loss). mcq

4. Drugs which causes hyperprolactinemia

Antipsychotics( such as haloperidol, chlorpromazine ), metochlopramide, domperidone, methyldopa,
can produce hyperprolactinemia.
Prolactin levels often < 1000mU/l
Conventional anti-psychotics produces more prolactin than atypical.

Those who enjoy medicine, read the following. Others start the MCQs.
If you can understand following talk about dopamine, you can understand the actions and side effects of
many drugs without memorizing.

There are 4 main places in the brain where dopamine exert it’s effects
1. Hypothalamus-Pituitary axis – Dopamine inhibits prolactin
2. Meso-limbic system – Increase dopamine produces psychotic symptoms (hallucinations..)
3. Vomiting center in the medulla – Dopamine induces vomiting
4. Basal Ganglia ( Substantia Nigra) – Lack of dopamine in basal ganglia produces Parkinson disease)

Now we work out the effects and side effects of the drugs which have effect on dopamine system

In hypothalamo-pituitary axis
Bromcriptine / cabegoline are dopamine agonist used as first line treatment against prolactinoma
• So, both these drugs can also be used in parkinson disease too.
• However, dopamine agonist effect in the mesolimbic system produces psychotic symptoms
• Increase dopamine induces vomiting centre induces vomiting

In Meso-limbic system
Anti-psychotics are dopamine antagonists act in mesolimbic system against psychosis and schizophrenia.
• Due to this anti-dopaminergic actions of Anti psycotics. hypothalmo-pituitary axis produces more
prolactin and galactorrhea
• Due to this anti-dopaminergic in the basal ganglia it produces drug induce parkinsonism.

Vomiting centre
Anti-emetics such as metoclopramide and domperidone antagonize the dopamine in the vomiting centre and
produces anti-emesis
• Both these drugs can be used to produce increased lactation to those newly delivered mothers who don’t
produce adequate breast milk-specially soon after delivery.
• Metochlopramide can cause movement related disorder like dystonic reactions-MCQ

Basal-ganglia
Drugs used in parkinson disease exerts their dopamine agonist action in substantia nigra.
• However, these drugs can even act on meso-limbic system and can produce hallucinations.
Here are the mcqs. Good luck!

01 A 43 feels that her weeding rind size increased recently and

the shoe sizes also increased. In addition, she feels excessive
sweating and headache. Clinical examination reveals
bitemporal hemianopia. Treating doctor suspects that patent
has acromegaly. Which of the following least consistent with
acromegaly
A. Hypertension
B. Heart failure
C. Carpal tunnel syndrome
D. High blood pressure
E. Hypoglycemic attacks
02 A 45 year old man for an yearly health checkup. He is
healthy and not on any medications. Laboratory assistant
mistakenly has taken the S. prolactin which was very high.
Other blood tests were normal. Patient was inquired by the
doctor and found to be entirely asymptomatic. Select the
most likely cause?
A. Micro-prolactinoma
B. Macroprolactinoma
C. Macro-prolactinemia
D. Non-functioning adenoma
E. Craniopharyngioma
03 A 30 year old mother of 2 children presents with
oligomenorrohea and expressive galactorrhea. He younger
child is 7 years old. She is otherwise well, takes no regular
medication and her BMI is 23. Her blood test findings
shows hyperprolactinemia. Other tests were normal
Select the most likely cause.
A. Micro-prolactinoma
B. Macro-prolactinom
C. Macro-prolactinemia
D. PCOD
E. OCP
04 Which ONE of the following drugs will NOT cause
hyperprolactinaemia?
A. Cabergoline
B. Metoclopramide
C. Haloperidol
D. Chlopromazine
E. Risperidone

05 A55 year old man presents with recurrent headache with

altered vision. On visual examination he has bitemporal
 hemianopia. He denies any other symptom. Treating doctor
suspect a tumour in the pituitary. What is the most likely
tumour?
A. Macro-prolactinemia
B. Macro-prolactinoma
C. ACTH-secreting adenoma
D. Non functioning pituitary tumour
E. GH secreting adenoma
6 A 55 year old man who has diagnosed with a pituitary
adenoma which actively secrete a hormone. He has
undergone transsphenoidal surgery. Histology shows
basophilic tumor. Select the most likely tumor.
A. GH secreting adenoma
B. Prolactin secreting adenoma
C. Rathke's cleft cysts
D. Craniopharyngioma
E. ACTH secreting adenoma
7 A 28 year old immigrant woman presents with amenorrhoea
since the delivery of her second baby who is 4years old now.
Further questioning reveals that she was resuscitated with
2pints of blood due to heavy post partum hemorrhage. She
couldn’t produce enough milk to feed the newborn, so the
baby was started on formulated milk feeding since day4.
Likely diagnosis?
A. PCOD
B. Kallman syndrome
C. Pheochromocytoma
D. Cushing’s reflex
E. Sheehan syndrome
8 A 40-year lady complains of decreased libido, amenorrhea
and galactorrhea. Her serum prolactin levels are
10,000mU/1. what is the likely cause of hyperprolactinemia?
A. PCOD
B. Stress
C. Pregnancy
D. Prolactin secreting micro-adenoma
E. Prolacting secreting macro-adenoma
9 A 40-year lady complains of decreased libido, amenorrhea
and galactorrhea. Her serum prolactin levels are 1300mU/1.
what is the likely cause of hyperprolactinemia?
A. Drug induced
B. Stress
C. Pregnancy
D. Prolactin secreting micro-adenoma
E. Prolacting secreting macro-adenoma
10 A 35 year old lady with functional pituitary tumor which is
 18mm. She was planned to undergo the surgery and waiting
for the dates. She develops sudden severe headache with
double vision. Most likely diagnosis
A. Cerebral metastasis
B. Retinal hemorrhage
C. Pituitary apoplexy
D. SAH
E. Amaurosis fugax

11 A 35 year old man presents with worsening headache.

Examinations shows he has bitemporal hemianopia. MRI
shows 1,7cm tumor in the pitutary fossa.
What is the treatment of choice?
A. New MRI in 3 moths
B. Surgery
C. Somatostatin analogue
D. Chemotherapy
E. Radiotherapy
12 Which of the following medicine doesn’t cause
hyperprolactinemia?
A. Methyldopa
B. Verapamil
C. Domperidone
D. Chlopromazine
E. Bromocriptine
13 17 year old girl presents with expressive galactorrhea for 2
days. She denies any other symptom. But she had her last
period 2 months ago. What is the initial investigation of
choice?
A. Skull X-ray
B. Urine beta HCG
C. Pelvic USS
D. S. prolactin
E. Thyroid function test
14 A 55 year old man who has diagnosed with a pituitary
adenoma which actively secrete a hormone. He has
undergone transsphenoidal surgery. Histology shows an
eosinophilic tumor. Select the most likely tumor.
A. GH secreting adenoma
B. Prolactin secreting adenoma
C. Rathke's cleft cysts
D. Craniopharyngioma
E. ACTH secreting adenoma
15 A32 year old female delivered a full term baby who is
healthy with 3.5kg birth weight. No complications post
partum. However, mother doesn’t produce enough milk.
 What hormone deficiency causes this condition?
A. Oestrogen
B. Progesterone
C. Prolactin
D. FSH
E. LH
16 A 35 year-old women investigated for amenorrhoea and
galctorroea. Blood test shows s.prolactin 1600mU/l. MRI:
microprolactinoma. Iniatial treatment of choice
A. Metochlopramide
B. Methyldopa
C. Chlorpromazine
D. Bromocriptine
E. Domperidone
17 A 40-year lady complains of decreased libido, amenorrhea
and galactorrhea. She has gaining weight and became
intolerant to cold last few months. Ex: moon face, Dry skin
Pulse 55. Her serum prolactin levels are 1300mU/1. what is
the likely cause of hyperprolactinemia?
A. Drug induced
B. Hypothyroidism
C. Pregnancy
D. Prolactin secreting micro-adenoma
E. Prolacting secreting macro-adenoma
18 55 year old woman with a non-functioning pituitary tumor
waiting for the resection developed galactorrhea. Blood test:
Prolactin 1200mU/l, TSH-Normal, GH-Normal, ACTH-
Normal. Likely cause
A. Malignant transformation of the tumor
B. Non-functioning tumor transformed to functioning tumor
C. Stalk compression
D. Macro-prolactinemia
E. Stress induced

Answers
1 E. 4 Hormones increases the blood sugar Must know in plab
1. Glucagon
2. Corticosteroids
3. Adrenaline
4. Growth hormone

Don’t worry, we will learn everything about GH when we do the pituitary hormones part.
2 C
3 A.
It is the commonest cause for primary hyperprolactinemia
4 A. cabergoline and bromocriptine inhibit prolactin secretion
5 D
6 E
7 E
8 E
9 D. If prolactin levels are between 1000-6000mU/l, most likely cause is micro-prolactinoma
10 C. Just want to introduce some pituitary conditions before we go to the topic.
11 B
12 E
13 B
14 A
15 C
16 D.
17 B
18 c