MRI of the brain did not show any pituitary gland abnormalities.
Other pituitary function tests and thyroid function tests were assessed
and were normal. Patient was started on Bromocriptine 1.25 mg nocte increasing
to 2.5 mg nocte for a week and 2.5 mg BD over the next two weeks. Serum
prolactin level 6 weeks later were 85 mIU/L
Two months after the commencement of the treatment her periods resumed.
Initially these were scanty but soon became regular. Bromocriptine was
stopped prior to her discharge from the hospital. She was followed up
in the Endocrine Clinic where her serum Prolactin was 135 mIU/L 2 months
later. Although the prolactin levels remained slightly raised after the
cessation of bromocriptine it was decided to follow her up on regular
basis. Patient conceived soon afterwards and had a successful pregnancy.
Hyperprolactinaemia following spinal cord injury (SCI) has been reportedl.
1-4 Upto 9.8 % of young women aged 20-33 years with SCI are known to
develop galactorrhea-amenorrhea syndrome (GAS). There are multiple causes
of hyperprolactinaemia.
These include physiological, i.e. pregnancy, breast feeding, post partum
states and exercise, etc. Common pathological causes include prolactin
secreting pituitary tumours, pituitary stalk section, hypothyroidism
and renal failure. Pharmacological causes include TRH, psychotropic
drugs, oral contraceptives, Methyldopa etc.
Exactly what the mechanism leads to amenorrhea in the patients with
dorsal spine injuries is unknown. Suggested mechanism in the pathogenesis
of this syndrome in SCI include contusion or concussion of the pituitary
stalk (2), spinal shock with elevation of the CNS endorphins.3 Irritation
of the afferent neuronal pathways of the cord and intercostal nerves
to the memory gland can also contribute to the magnitude of hyperpolactinaemia.4
The levels are therefore usually higher in patients with D4-D6 injuries
than in patients with D12-L5 injuries. Stimulation of the breast and
nipple may cause a rise in prolactin levels and non puerpal lactation
can occur following stimulation of 4th, 5th and 6th intercostal nerves.
During pregnancy and post partum period due to prevailing lactotroph
hyperplasia, women are predisposed to develop this syndrome especially
if they sustain SCI.4 Neurogenic In summary, the most likely cause of
galac galactorrhea amenorrhea may be similar to torrhea amenorrhea syndrome
is irritation that seen in the nursing mothers
The exact mechanism of GAS syndrome occurring in chest wall burns, chest
wall trauma or intercostal nerves injuries, maybe similar to the neuroendocrine
reflex of suckling or irritation of the breasts or nipple. This may
inhibit the secretion of the hypothalamic LRH, block the ovulatory surge
of gonadotrophins and increase the prolactin levels.5
Herpes zoster neuralgia can also lead to hyperprolactinaemia. This has
also been observed in patients with self stimulation of the breast,
following dorsal laminectomy for spinal tumours and post thoracotomies.6,7
Intercostal nerve blocks and bromocriptine therapy reduce the prolactin
levels to normal, but does not noticeably reduce milk secretions. One
or more prolactin releasing factors probably mediate acute release of
prolactin.7
Stress is an important cause of hyperprolactinaemia and could be responsible
for this condition in SCI patient. It could be mediated through the
release of VIP and PHI (Peptide-Histidine-Isoleucine). Immuno-neutralization
of these peptides can lead to blockade of stress induced PRL release.
Increased prolactin can act on the hypothalamus and inhibits GRH. Gonadotrophin
inhibition in turn will lead to amenorrhea. A large number of prolactin
releasing factors have been postulated including B-Endorphins, Leuencephalin,
Dysnorphin and Alpha and Beta Neoendorphins, Bombesins, Substance P
Neurostensin, Histamine, Melatonin, Bradykinin, etc.8 Gynecomastia following
spinal cord disorder in males is also a recognised condition.9 Male
patients with dorsal spine injuries should have full endocrine workup
including plasma testosterone, LH, FSH, PRL, TSH, LFTs along with examination
of testicles to avoid any secondary complications like sterility.
In summary, the most likely cause of galactorrhea amenorrhea syndrome
is irritation of afferent pathway of the cord leading to irritation
of intercostal nerves. Other likely causes for this syndrome could be
stress it self which causes hyperprolactinameia me diated through the
release of VIP and PHI. Neutralization of these peptides lead to the
blockade of stress induced PRL. The suggestion that pituitary injury
itself can contribute to galactorrhea amenorrhea syndromes is unlikely
as patients do not demonstrate any other symptoms relating to pituitary
problems. A prospective study is currently being carried out in our
center to compare a similar problem of hyperprolactinaemia in male patients
with high cervical or lower lumbar spine injuries.
| 1. |
Berezin M, Ohry A, et al; Hyperprolactinaemia,
galactorrhea and amenorrhea in women with spinal cord injury; Gynecol.
Endocrinol. 3 (1989) 159-163.. |
| 2. |
Guthman L; Spinal Cord Injuries; 1
st Edition (1973) 461-71. |
| 3. |
Comarr E (1966) ; Observation on menstruation
and pregnancy among female spinal cord injured patients; Paraplegia
3 (1966) 263-70. |
| 4. |
.Cooper I, Sand H; Metabolic disorders
in paraplegics; Neurology 2 (1952) 332-40. |
| 5. |
Morley J E, Dawson M, Hodgkinsson H,
Kalk US ;Galactorrhea and hyperprolactinaemia associated with chest
wall injury; J. Clin. Endocrin. Metab. 45 (1977), 931-5. |
| 6. |
Herman V, Kath W J and de Moor N G;
Serum prolactin after chest wall surgery, elevated levels after
mastectomy; J. Clin Endocrinol. Metab. 52 (1981) 148-51. |
| 7. |
Gumm E G; Non puerpal galactorrhea;
Q B North West University Med School; 29 (1955) 350. |
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Blankstein J, Reyes F I, Winter) S
D; Endorphins and the regulation of human menstrual cycle; Clin.
Endocrin; 14 (1981) 287-94. |
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Heruti R J, Danker R, Berezin M; Gynecomastia
following spinal cord disorder; Arch Phys. Med. Rehabil.; 78 (1997);
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