Prolactinoma and Hyperprolactinaemia

Somatotroph adenomas of the pituitary secreting prolactin, and other conditions presenting with elevated serum prolactin levels. Diagnosis requires blood testing of prolactin levels, a full drug history and frequently MRI scanning.

General examination

To diagnose prolactinoma and hyperprolactinaemia a detailed and full general examination is mandatory in the initial assessment of a patient. 

Breasts

Breasts and axillae should be examined for masses particularly in the case of unilateral galactorrhoea, in case of malignancy.

Galactorrhoea should be confirmed and documented as either spontaneous or expressible by gently exerting pressure on both sides of the nipple.

Serum prolactin levels may increase after breast examination and so should always be checked before this is performed.

Assess for virilisation

PCOS may be associated with mild elevations of prolactin, which should not require specific investigation or treatment.

Assess thyroid status and examine thyroid

Mild elevations of prolactin may occur with hypothyroidism. LINKS thyroid status/thyroid exam

Pituitary status


Visual acuity and visual fields

Full assessment of acuity and fields is mandatory in all patients suspected of pituitary disease to detect chiasmal compression or other involvement of the optic pathways.


Visual fundoscopy

Disc pallor is indicative of long term visual loss which may not recover after decompression of the optic pathway.

Papilloedema is an indicator of raised intracranial pressure requiring urgent investigation.


Cranial nerves III-XII

Full cranial nerve assessment is important in all patients with suspected pituitary tumours.

The nerves of the cavernous sinus are most frequently affected, though a VI nerve palsy may be a false localising sign associated with increased intracranial pressure.


Skin

Fine wrinkling of the skin occurs in hypopituitarism.

Pallor may also occur with a normocytic normochromic anaemia with glucocorticoid deficiency.

Doughy pallid 'myxoedematous' skin may be seen with loss of thyroid function. Doughy skin with soft tissue swelling also occurs in growth hormone excess.

Café au lait patches, skin tags and axillary freckling may indicate associated syndromes, for example neurofibromatosis, or McCune Albright syndrome.


Thyroid status

Specifically seek signs of thyroid dysfunction.


Musculature

Muscle wasting may occur in glucocorticoid deficiency.

Proximal myopathy and slow relaxing reflexes may occur with loss of thyroid function.