Symptoms of persistent galactorrhea-amenorrhea syndrome

The most common reason for the treatment of women with persistent galactorrhea-amenorrhea syndrome with a doctor is a disorder of the menstrual cycle and / or infertility. The first varies from opsoligomenorei to amenorrhea, most often secondary. Polymenorrhea is not characteristic for hyperprolactinemic syndrome, except for its symptomatic forms associated with primary hypothyroidism. Approximately every fifth patient reports that menstruation has been irregular since menarche, the time of onset of which in many patients is somewhat delayed. In the future, particularly violent disorders of the menstrual cycle are revealed in the period of chronic stressful situations (examination session, long-term illnesses, conflict situations). The development of amenorrhea often coincides with the onset of sexual activity, the abolition of previously used oral contraceptives, the interruption of pregnancy, childbirth, the introduction of intrauterine contraceptives, or surgical intervention. As a rule, patients with the syndrome of persistent galactorrhea-amenorrhea are more concerned about violations of the menstrual cycle and / or infertility.

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

Its degree varies from abundant, spontaneous, to individual 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 purposeful examination. As the duration of the disease increases, the galactorrhea, as a rule, decreases. The severity of galactorrhea is usually assessed on the following scale: unstable galactorrhea - (±), lactorrhea (+) - single drops with strong pressure, lactorrhea (++) - jet or copious drops with mild pressing, lactorrhea (+++) - spontaneous separation of milk .

Infertility, both primary and secondary, is one of the main complaints in the syndrome of persistent galactorrhea-amenorrhoea. The elimination of infertility for many women with the syndrome of persistent galactorrhea-amenorrhea is the main goal of treatment. Sometimes in anamnesis in patients with the syndrome of persistent galactorrhea-amenorrhea miscarriages in the early stages of pregnancy (8-10 weeks). However, stillbirth and premature birth are not typical. In most patients, libido is decreased, there is no orgasm, frigidity is observed, dyspareunia is possible, but these complaints are not actively presented by patients, and the need for correction of these disorders for most patients seems to recede into the background in comparison with the menstrual cycle and infertility. Some women note a clear association of sexual disorders with the development of the disease.

If the classical description of Chiari emphasized the depletion of patients with the syndrome of persistent galactorrhea-amenorrhea on a background of abundant galactorrhea ("milky dry"), in modern conditions, on the contrary, approximately 50% of patients show moderate obesity. Quite often, women are concerned about the excessive growth of hair on the face, around the nipples and on the white line of the abdomen.

Headaches, including the type of migraine, dizziness are possible and in the absence of adenoma. Neurosurgeons, who have extensive experience in monitoring patients with macro- and microadenomas, believe that about half of women who have prolactotrophic adenomas complain of headaches. Subjective signs of impaired optic nerve function in women with prolactinomas are quite rare.

Some patients have emotional-personality disorders, a tendency to depressive states. These changes in many cases can be considered situationally conditioned (infertility and related family conflicts). However, in patients who consider the primary goal of treatment the restoration of fertility, these emotional and personality disorders are observed less often. At the same time, unmarried women who do not want to become pregnant, striving to be "completely healthy" and linking with the galactorrhea all the changes in their state of health, sometimes present a serious problem for the doctor, since the methods for treating emotional and personality disorders in this contingent are not sufficiently developed.

Various nonspecific complaints - increased fatigue, weakness, pulling pains in the heart area without a clear localization and irradiation, are also common among patients with the syndrome of persistent galactorrhea-amenorrhea, mainly among people with emotional disorders. Previously considered to be a characteristic sensation of "wiggling the fetus" and pain in the lower back are almost not observed. A small pasty of the eyelids, face, lower extremities often occurs with the syndrome of persistent galactorrhea-amenorrhea and can be one of the complaints with which patients come to the doctor.

Men with hyperprolactinemia consult a doctor, usually in connection with impotence and a decrease in libido. Gynecomastia and galactorrhea are relatively rare. The main cause of hyperprolactinemia in men are the pituitary macroadenomas, as a result of which the symptoms of the loss of tropic hormones of the pituitary gland and the growth of the intracranial tumor predominate in the clinical picture of the disease: headaches occur in 68% of men with prolactinomas, and visual function impairments in 65%.

The clinical manifestations of hyperprolactinaemia of drug origin range from minimal galactorrhea and / or menstrual irregularity to a typical syndrome of persistent galactorrhea-amenorrhea. Drug hyperprolactinemia for a long time is asymptomatic. In primary hypothyroidism, the clinical manifestations of hyperprolactinaemia may be different depending on the time of occurrence of hypothyroidism. If the primary hypothyroidism develops in the preubertal period, the girls develop the so-called Van Vika-Grambach syndrome (premature puberty, galactorrhea, menometrorrhagia). Primary hypothyroidism in adulthood leads to a violation of the menstrual cycle up to amenorrhea, less often - polymenorrhea. Even subclinical primary hypothyroidism can be the cause of the syndrome of persistent galactorrhea-amenorrhoea.

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

In persons with somatic pathology, in particular renal and hepatic insufficiency, the clinical manifestations of hyperprolactinaemia vary to a large extent and do not have a direct connection with the level of prolactin in the blood. It is important that in some patients with somatic pathology gonadal dysfunction can be the reason for contacting a doctor.

At an objective inspection of patients with an essential syndrome of persistent galactorrhea-amenorrhea can be divided into 4 groups:

• 1-st - practically healthy ("pure" syndrome of persistent galactorrhea-amenorrhea);
• 2 nd - a syndrome of persistent galactorrhea-amenorrhea with obesity and hypothalamic stigmata ("dirty" elbows and neck, "pearly" striae), with disturbance of water-electrolyte metabolism;
• 3rd - the syndrome of persistent galactorrhea-amenorrhea is combined with symptoms of hyperandrogenia (in women) - hypertrichosis, acne, sialotherapy, seborrhea of the scalp, thinning of the hair on the head;
• 4th - having a combination of symptoms.

Very rarely, in spite of the laboratory-determined normal level of somatotropic hormone, there are patients with the syndrome of persistent galactorrhea-amenorrhea and mild acromegaloid stigmata.

When examining the cardiovascular system in the syndrome of persistent galactorrhea-amenorrhea, bradycardia and a tendency to hypotension are often recorded. All these symptoms make it necessary to carefully examine patients in order to exclude hypothyroidism from them. The genesis of these "hypothyroid" symptoms remains unclear. Some of them, for example bradycardia, tried to explain by peripheral dopaminergic insufficiency.

When examining the respiratory system, digestive system, urinary system of any specific for the syndrome of persistent galactorrhea-amenorrhea signs can not be identified, except in cases when the syndrome of persistent galactorrhea-amenorrhea is symptomatic and is associated with somatic diseases.

The functional state of the thyroid gland in the syndrome of persistent galactorrhea-amenorrhea especially attracts the attention of clinicians, since first of all autoimmune thyroiditis of the postpartum period is often accompanied by a syndrome of persistent galactorrhea-amenorrhea, and other forms of hypothyroidism can also lead to hyperprolactinaemia. In addition, diffuse toxic goiter and associated mastopathy can be accompanied by galactorrhea. Finally, it is known that the effect of prolactin on the exchange of thyroid hormones has been revealed in an animal experiment. Quite often, patients with the syndrome of persistent galactorrhea-amenorrhea have hyperplasia of this gland of I-II degree, but there is no convincing evidence that it occurs more often than on average in the population.

A change in hairiness in the syndrome of persistent galactorrhea-amenorrhea is often observed and, as shown at present, is due to the hyperproduction of the adrenal glands of dehydroepiandrosterone sulfate under the influence of excess prolactin.

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

Very important for the diagnosis of the syndrome of persistent galactorrhea-amenorrhea is the gynecological examination: the detection of uterine hypoplasia, the absence of symptoms of "pupil" and "tension" of mucus. However, it should be noted that at present, patients with the syndrome of persistent galactorrhea-amenorrhea without severe hypoplasia of the internal genitalia are present in early diagnosis, moreover, in some patients, even a slight increase in the size of the ovaries is observed.

[1], [2], [3], [4], [5]