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The causes of hyperprolactinemia are shown in Table 26 2 Chronic nipple stimulation, nipple piercing, augmentation or reduction mammoplasty, and mastectomy may stimulate PRL secretion The pituitary tumor of acromegaly can cosecrete GH and PRL Hyperprolactinemia may also be idiopathic Increased pituitary size is a normal variant in young women About 10% of hyperprolactinemic patients are found to be secreting macroprolactin, a relatively inactive big prolactin ; pituitary MRI is normal in 78% of cases The differential diagnosis for galactorrhea includes the small amount of breast milk that can be expressed from the nipple in many parous women that is not cause for concern Nipple stimulation from nipple rings, chest surgery, or acupuncture can cause galactorrhea; serum PRL levels may be normal or minimally elevated Some women can have galactorrhea with normal serum PRL levels and no discernible cause (idiopathic) Normal breast milk may be various colors besides white Bloody galactorrhea requires an evaluation for breast malignancy

Summary

developing osteoporosis; such women require periodic bone densitometry Pituitary macroprolactinomas (> 10 mm in diameter) have a higher risk of progressive growth, particularly during treatment with estrogen or testosterone replacement therapy or during pregnancy Therefore, patients with macroprolactinomas should not be treated with sex hormone replacement therapy (HRT) unless they are in remission with dopamine agonist medication or surgery Pregnant women with macroprolactinomas should continue to receive treatment with dopamine agonists throughout the pregnancy to prevent tumor growth

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Medications known to increase PRL should be stopped if possible Hyperprolactinemia due to hypothyroidism is corrected by thyroxine Patients with hyperprolactinemia not induced by drugs, hypothyroidism, or pregnancy should be examined by pituitary MRI Women with microprolactinomas who have amenorrhea or are desirous of contraception may safely take oral contraceptives or estrogen replacement there is minimal risk of stimulating enlargement of the microadenoma Patients with infertility and hyperprolactinemia may be treated with a dopamine agonist in an effort to improve fertility Women who elect to receive no treatment have an increased risk of

Dopamine agonists are the initial treatment of choice for patients with giant prolactinomas and those with hyperprolactinemia desiring restoration of normal sexual function and fertility Of the ergot-derived dopamine agonists, cabergoline is usually the best tolerated and is prescribed beginning with a dosage of 025 mg orally once weekly for 1 week, then 025 mg twice weekly for the next week, then 05 mg twice weekly Further dosage increases may be required monthly, based on serum PRL levels, up to a maximum of 15 mg twice weekly Higher doses of cabergoline, ( 2 mg daily, have been reported to cause mitral valve regurgitation Alternative drugs include bromocriptine (125 20 mg/d orally) Women who

An operator is a symbol that causes C# to take an action. The assignment operator (=) assigns a value to an object or variable. C# includes four simple arithmetic operators, +, -, *, and /, and numerous variations such as +=, which increments a variable on the left side of the operator by the value on the right side. When you divide integers, C# discards any fractional remainder. The modulus operator (%) returns just the remainder from integer division. C# includes numerous special operators, such as the self-increment (++) and self-decrement (--) operators.

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As you can imagine, each job required considerable time to complete, especially when additional support programs were necessary. Once the job finished, the operator got the output and made it available to the programmer. These operations took anywhere from a few hours to many days. This program development cycle was ineffective because of the inefficient relationship between program development time and the time required to run a job. Another problem was poor CPU utilization, because jobs performing I/O left the CPU idle. During this period, computers and computing time were not free in fact, they were quite expensive. To minimize any unnecessary costs and increase CPU utilization, system designers developed a technique called batch processing.

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