Symptoms of persistent galactorrhea-amenorrhea syndrome

The most common reason for women with persistent galactorrhea-amenorrhea syndrome to seek medical attention is menstrual irregularities and/or infertility. The former varies from opso-oligomenorrhea to amenorrhea, most often secondary. Polymenorrhea is not typical of hyperprolactinemic syndrome, with the exception of its symptomatic forms associated with primary hypothyroidism. Approximately every fifth patient reports that menstruation has been irregular since menarche, the onset of which is somewhat delayed in many patients. Subsequently, menstrual irregularities are especially clearly detected during chronic stress situations (exam sessions, long-term illnesses, conflict situations). The development of amenorrhea often coincides in time with the onset of sexual activity, discontinuation of previously used oral contraceptives, termination of pregnancy, childbirth, insertion of intrauterine contraceptives, or surgery. As a rule, patients with persistent galactorrhea-amenorrhea syndrome are more concerned about menstrual irregularities and/or infertility.

Galactorrhea is rarely the first symptom of persistent galactorrhea-amenorrhea syndrome (in no more than 20% of patients) and even more rarely the main complaint. Sometimes, even with significantly increased prolactin levels, it is absent.

Its degree varies from abundant, spontaneous, to single drops with strong pressure. In the latter case, patients themselves, as a rule, do not notice galactorrhea; it is detected by a doctor during a targeted examination. As the duration of the disease increases, galactorrhea, as a rule, decreases. The severity of galactorrhea is usually assessed according to the following scale: inconstant galactorrhea - (±), lactorea (+) - single drops with strong pressure, lactorea (++) - jet or abundant drops with gentle pressure, lactorea (+++) - spontaneous secretion of milk.

Infertility, both primary and secondary, is one of the main complaints in persistent galactorrhea-amenorrhea syndrome. Elimination of infertility is the main goal of treatment for many women with persistent galactorrhea-amenorrhea syndrome. Sometimes, patients with persistent galactorrhea-amenorrhea syndrome have a history of early pregnancy miscarriages (8-10 weeks). However, stillbirth and premature birth are not typical. Most patients have decreased libido, no orgasm, frigidity, and possible dyspareunia, but patients do not actively present these complaints, and the need to correct these disorders for most patients seems to recede into the background compared to menstrual irregularities and infertility. Some women note a clear connection between sexual disorders and the development of the disease.

If the classical description of Chiari emphasized the exhaustion of patients with persistent galactorrhea-amenorrhea syndrome against the background of abundant galactorrhea ("milk hunger"), then in modern conditions, on the contrary, approximately 60% of patients are moderately obese. Quite often, women are bothered by excessive hair growth on the face, around the nipples and along the white line of the abdomen.

Headaches, including migraine-type headaches, dizziness are possible even in the absence of adenoma. Neurosurgeons with extensive experience in observing patients with macro- and microadenomas believe that approximately half of women with prolactotroph adenomas complain of headaches. Subjective signs of optic nerve dysfunction in women with prolactinomas are quite rare.

Some patients have emotional and personal disorders, a tendency to depressive states. In many cases, these changes can be considered situationally conditioned (infertility and related family conflicts). However, in patients who consider the restoration of fertility to be the main goal of treatment, the above-mentioned emotional and personal disorders are observed less frequently. At the same time, unmarried women who do not want to get pregnant, who strive to be "absolutely healthy" and associate all changes in their well-being with galactorrhea, sometimes pose a serious problem for the doctor, since methods for treating emotional and personal disorders in this contingent are not sufficiently developed.

Various non-specific complaints - increased fatigue, weakness, nagging pain in the heart area without clear localization and irradiation, are also common among patients with persistent galactorrhea-amenorrhea syndrome, mainly among people with emotional disorders. The previously considered characteristic sensation of "fetal movement" and pain in the lower back are now almost never observed. Slight puffiness of the eyelids, face, lower extremities is often seen with persistent galactorrhea-amenorrhea syndrome and may be one of the complaints with which patients come to the doctor.

Men with hyperprolactinemia usually seek medical attention due to impotence and decreased libido. Gynecomastia and galactorrhea are relatively rare. The main cause of hyperprolactinemia in men is pituitary macroadenomas, as a result of which the clinical picture of the disease is dominated by symptoms of loss of pituitary tropic hormones and intracranial tumor growth: headaches occur in 68% of men with prolactinomas, and visual impairment occurs in 65%.

Clinical manifestations of drug-induced hyperprolactinemia vary from minimal galactorrhea and/or menstrual irregularities to typical persistent galactorrhea-amenorrhea syndrome. Drug-induced hyperprolactinemia is asymptomatic for a long time. In primary hypothyroidism, clinical manifestations of hyperprolactinemia may vary depending on the time of hypothyroidism onset. If primary hypothyroidism develops in the prepubertal period, girls develop the so-called Van Wyck-Grambach syndrome (precocious puberty, galactorrhea, menometrorrhagia). Primary hypothyroidism in adulthood entails menstrual irregularities up to amenorrhea, less often - polymenorrhea. Even subclinical primary hypothyroidism can be the cause of persistent galactorrhea-amenorrhea syndrome.

Hyperprolactinemia is found in 30-60% of patients with poly- and sclerocystic ovary syndrome, while galactorrhea may be absent. In patients with adrenal cortex dysfunction, galactorrhea is rare, and usually only transient hyperprolactinemia is detected.

In individuals with somatic pathology, in particular with renal and hepatic insufficiency, the clinical manifestations of hyperprolactinemia vary significantly and have no direct relationship with the level of prolactin in the blood. It is important that in some patients with somatic pathology, it is the dysfunction of the gonads that may be the reason for seeking medical attention.

During an objective examination, patients with essential syndrome of persistent galactorrhea-amenorrhea can be divided into 4 groups:

• 1st - practically healthy (“pure” syndrome of persistent galactorrhea-amenorrhea);
• 2nd - persistent galactorrhea-amenorrhea syndrome with obesity and hypothalamic stigmas (“dirty” elbows and neck, “pearlescent” striae), with impaired water-electrolyte metabolism;
• 3rd - persistent galactorrhea-amenorrhea syndrome is combined with symptoms of hyperandrogenism (in women) - hypertrichosis, acne, sialorrhea, seborrhea of the scalp, thinning hair on the head;
• 4th - having a combination of symptoms.

Very rarely, despite laboratory-determined normal levels of somatotropic hormone, patients with persistent galactorrhea-amenorrhea syndrome and mild acromegaloid stigmas are encountered.

When examining the cardiovascular system in persistent galactorrhea-amenorrhea syndrome, bradycardia and a tendency to hypotension are often recorded. All these symptoms require careful examination of patients to exclude hypothyroidism. The genesis of these "hypothyroid" symptoms remains unclear. Some of them, such as bradycardia, have been attempted to be explained by peripheral dopaminergic insufficiency.

When examining the respiratory system, digestive organs, and urinary system, it is not possible to identify any signs specific to persistent galactorrhea-amenorrhea syndrome, except in cases where persistent galactorrhea-amenorrhea syndrome is symptomatic and associated with somatic diseases.

The functional state of the thyroid gland in persistent galactorrhea-amenorrhea syndrome is of particular interest to clinicians, since autoimmune thyroiditis of the postpartum period is often accompanied by persistent galactorrhea-amenorrhea syndrome, and other forms of hypothyroidism can also lead to hyperprolactinemia. In addition, diffuse toxic goiter and associated mastopathy can be accompanied by galactorrhea. Finally, it is known that an experiment on animals revealed the effect of prolactin on the metabolism of thyroid hormones. Patients with persistent galactorrhea-amenorrhea syndrome often have grade I-II hyperplasia of this gland, but there is no convincing evidence that it occurs more often than the average in the population.

Changes in hairiness in persistent galactorrhea-amenorrhea syndrome are often observed and, as has now been shown, are caused by hyperproduction of dehydroepiandrosterone sulfate by the adrenal glands under the influence of excess prolactin.

The mammary glands have a soft consistency, often with age-inappropriate involutional changes and signs of fibrocystic mastopathy. Breast cancer occurs in persistent galactorrhea-amenorrhea syndrome no more often than the average in the population. Gigantomastia and macromastia are extremely rare. Despite galactorrhea, mastitis-like changes and inflammatory changes in the areola are rare, mainly in those who have been ill for a long time (for decades). In primary amenorrhea or early onset of persistent galactorrhea-amenorrhea syndrome, the mammary gland is of the juvenile type, with pale flat or inverted nipples.

Gynecological examination data are very important for diagnosing persistent galactorrhea-amenorrhea syndrome: detection of uterine hypoplasia, absence of "pupil" symptoms and "tension" of mucus. However, it should be noted that at present, with early diagnosis, there are patients with persistent galactorrhea-amenorrhea syndrome without pronounced hypoplasia of the internal genital organs, moreover, some patients even have a slight increase in the size of the ovaries.

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