Prolactinoma, a prolactin-secreting benign tumor (adenoma) of the anterior pituitary gland, is the most common type of pituitary tumor existing in 5 to 10 percent of the adult population1 and accounts for 30 to 40 percent of all pituitary adenomas;2, 3 however, symptomatic prolactinomas are fairly uncommon.4 In those diagnosed with symptomatic prolactinomas and consequently hyperprolactinemia (excess levels of the prolactin hormone in the blood) the condition can impact fertility, libido, vision, and neurological health in both women and men, and affect a woman’s bone health.2 Prolactinomas are four to five times more common in women than in men.5
In a healthy, non-pathological woman prolactin, also known as luteotropic hormone or luteotropin, is responsible for the growth and development of breasts during pregnancy and the initiation and sustained production of breast milk following delivery (provided that a woman nurses).4 In men, the normal role of prolactin is unclear, but it is suspected to play a role in male fertility.6
Pituitary tumors, including prolactin-secreting adenomas, “develop from one single abnormal cell that multiplies into many abnormal cells, eventually forming a tumor.” 3 The cause for this development is unknown, but prolactinoma has been suspected to be caused by the genetic condition Multiple Endocrine Neoplasmia Type 1 in some patients.2 Most often, prolactinomas are considered sporadic and therefore not genetic.4 In addition, there is animal research to support speculation of the role of estrogen and xenoestrogen bisphenol-A in the development of prolactinomas.7, 8
Once a prolactin-secreting adenoma has formed, it is likely to cause hyperprolactinemia. While other conditions can cause hyperprolactinemia -- such as other pituitary tumors that may block the flow of dopamine from the hypothalamus to the pituitary gland (dopamine is responsible for inhibiting prolactin in men and women), liver failure, kidney failure, some medications, stress and hypothyroidism1, 12 -- prolactinomas account for about 30 percent of hyperprolactinemia cases.9
Symptoms of prolactinoma vary for men and women and vary depending on whether or not the prolactinoma is of micro size (<10 mm) or macro size (>10 mm). Women may experience the following:2, 7
Men may experience the following symptoms as well:2, 7
Normally, hypothalamic dopamine inhibits the secretion of prolactin in a woman who is not pregnant or nursing; however, high levels of prolactin in the blood due to a secreting adenoma or nipple stimulation block the secretion of dopamine and therefore prolactin levels remain elevated. High prolactin levels also inhibit the release of luteinizing hormone releasing hormone (LHRH) from the hypothalamus and therefore inhibit the secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH) from the pituitary gland to the ovaries, thereby inhibiting ovulation and the menstrual cycle. Also as a result, low estrogen levels inhibit libido in women. Low LHRH secretion in men results in abnormal testicular function and therefore low testosterone levels, low libido, and decreased fertility.5
Prolactinomas greater than 10 mm in size (macroadenomas) can potentially press upon the optic nerve and/or invade the cavernous or sphenoid sinuses (location of the trigeminal nerve) causing headaches and vision changes.18 Various types of headaches are possible, including cluster headaches or short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Headaches are also possible in patients with prolactinoma despite tumor size.11, 19
A diagnosis of prolactinoma is made with blood tests showing elevated levels of prolactin on at least two occasions. Normal prolactin levels in both men and women who are not pregnant or nursing is 0 to 20 ng/ml. Micro-adenomas are suspected with the presentation of moderately elevated levels of prolactin at 30 to 200 ng/ml. Macro-adenomas usually present prolactin levels at over 500 ng/ml.1 Diagnosis is confirmed with a magnetic resonance imaging (MRI) scan or computerized tomography (CT) scan to “define the presence of a lesion compatible with a pituitary tumor.” 12
In Western medicine, the first line of approach to treating both symptomatic micro and macro secreting-prolactinomas is dopamine agonist drugs, including bromocriptine, pergolide, quinagolide, and cabergoline. These drugs mimic dopamine, and when given at the appropriate dosage, they normalize prolactin levels. Some patients will experience not only the normalization of prolactin levels, but also tumor shrinkage as a result of the medication. Consequently, such patients may be able to decrease their dosage over time and even cease taking medication after several years of treatment; however, the tumor may grow back.12, 2 Some patients have to take dopamine agonist drugs for life in order to manage the condition. Under proper care, all patients are monitored regularly with blood testing and imaging.2
Side effects of the listed dopaminergic drugs may include dizziness and nausea.2 In addition, the efficacy of the drugs may decrease with long-term use, so for both reasons, patients are started on low doses with dosage increased as needed. Most patients are able to tolerate these drugs, particularly cabergoline and quinagolide, but there are some people who are unable, and therefore, have to defer to other treatment options.13 Surgery and radiotherapy are the other two treatment options when a patient refuses or fails to respond well to pharmaceuticals.12, 2 Side effects of surgery may include damage to the normal tissue of the pituitary gland resulting in diabetes insipidus or the need for hormone replacement therapy. Other rare side effects of surgery may include post-operative bleeding, spinal fluid leak, stroke, or death.17
During pregnancy, a woman’s pituitary gland increases in size and prolactin levels naturally rise significantly and progressively as it prepares the breasts for lactation.1, 5 Since the dopamine agonists used to treat prolactinoma and hyperprolactinemia suppress prolactin levels in the blood, special consideration must be given to female patients who become or wish to become pregnant while being treated for both conditions.2 Research shows that dopamine agonists, particularly bromocriptine and cabergoline, do not pose adverse effects to babies born from mothers who were treated with these drugs -- even during the first trimester of pregnancy.16 “In women with microadenomas, pregnancy generally has little impact on their adenoma, delivery is normal and breast-feeding is allowed.” 15 However, as soon as pregnancy is suspected, women are taken off of the medication.
An Ayurvedic interpretation of the development and treatment of prolactin-secreting adenoma of the pituitary gland can be inferred from the Ayurvedic understanding of anatomy, tissue development, and doshic qualities. Considering first the location of the pituitary gland being in the head, particularly the brain, what is the significance of the head? Chapter 17, verse 12 of the Charaka Samhita states, “the head is the substratum of elan vital and all the sense faculties. So it occupies the first place amongst the vital organs of the body.” 27 This is in alignment with the western, scientific understanding of the the brain as the control center of the body, including the pituitary gland, which is referred to as the master gland.3
Being a part of the nervous system, Ayurveda considers the brain to be majja dhatu and part of the majjavaha srota. As stated in Principles of Ayurvedic Medicine by Dr. Marc Halpern, “the majja dhatu is commonly translated to mean the nervous system. However, the majja dhatu really relates to anything that fills an empty hollow space.” The pituitary gland is located in the base of the brain in a small, bony cavity (hollow space) of the skull called the sella turcica.3 Other relevant tissues involved in the condition of prolactinoma and majja dhatu include the optic nerve, which may be compressed by a macro-prolactinoma, and the neurotransmitter dopamine (also considered part of the nervous system and thus majja dhatu).
The Ayurvedic explanation of dhatu formation agrees with the western, scientific understanding of the impact of pituitary gland dysfunction on the reproductive system. As the sixth dhatu, majja dhatu precedes the formation of shukra dhatu (ovaries and testes) and therefore, provides the posaka (unstable) majja to the shukra agni to transform posaka majja into shukra.28 If the formation of majja dhatu and posaka majja is of poor quality or there is faulty shukra agni, then the formation quality, quantity and function of shukra and artava dhatu will be disturbed. Dr. Sarita Shrestha notes that while classical Ayurvedic texts do not refer to hormones, hormones are considered to be dhatu agni.20 This makes sense given the role of hormones as transformational signals and metabolic directors to other sites of the body. Thus, prolactin could be considered shukra dhatu agni or artava dhatu agni. Milk ducts, the stanyavaha srota, originate in the artava dhatu.
Classical Ayurvedic texts do not specifically discuss pituitary tumors or pituitary hormones; however, volume two of the Sushruta Samhita discusses the development and treatment of tumors (Gulma and Arbuda/Arvuda) and glandular swellings (Granthi).20, 21, 22, 23, 24, 25, 26 More specifically, gulma is understood to refer to hard, palpable masses in the abdomen (abdominal tumors), granthi refers to glandular swellings, benign tumors, or a tumor that is visible from the surface, and arbuda refers to a cancerous malignancy.29 Chapter 11, verses 11 - 12 of the Sushruta Samhita, volume two states,
Benign tumors, such as pituitary adenomas, are slow growing.30 Hence, one can infer from Sushruta that a prolactinoma is an arbuda or granthi.
In considering the subtle body, it is likely that the ajna chakra (6th) may play a role in the pathology and/or treatment of prolactinoma and other pituitary adenomas. The ajna (“third eye”) chakra, “is the command station of the body and mind … contains the subtle qualities of ether … [and] affects the functions of the pituitary gland and hypothalamus.” 28 Increased flow through this chakra correlates to excess function of the pituitary and hypothalamus glands.
“From an Ayurvedic perspective, tumor formation is a condition of vata/kapha origin. Vata is responsible for the faulty division of cells and kapha for their growth. Hence, vata pushes kapha out of balance resulting in tumor formation. Benign tumors take on a predominantly kapha appearance,” writes Dr. Halpern. He continues, “Kapha plays the predominant role [in the development of granthi - benign tumors] as it enters the affected dhatus.” 29 Considering the potential role of vata, even in the development of a benign tumor, apana vayu accumulates and becomes aggravated in the rasa of the purishavaha srota and overflows to the rasa and rakta dhatus of the rasavaha and raktavaha srotas respectively. Prana vayu (of the head) and vyana vayu (“plays a role in the movement of the nerve energy”28) relocate to the majja dhatu of the majjavaha srota causing cell division (movement).
Given that kapha (water and earth) is “the force of stability in the body,” is responsible for growth, and plays a lead role in the development of a benign tumor, kledaka kapha accumulates and becomes aggravated in the rasa of the annavaha srota, and overflows to the rasa and rakta dhatus of the rasavaha and raktavaha srotas respectively.28 Kapha then relocates to the majja dhatu of the majjavaha srota resulting in abnormal tissue growth (tumor) of lactotrophs of the anterior pituitary gland (majja).
According to the Sushruta Samhita, Chapter 11, verse 2, “the deranged and unusually aggravated vayu, etc. (pitta, kapha), by vitiating the flesh, blood and fat mixed with the kapha (of any part of the organism), give rise to the formation of round, knotty, elevated swellings which are called granthi (glandular inflammation).” In chapter 11, verses 3 - 5 “...the kaphaja granthi is slightly discolored and cold to the touch. It is characterised by a slight pain and excessive itching, and feels hard and compact as a stone. It is slow or tardy in its growth and exudes a secretion of thick white-coloured pus when it bursts.” 26 While Sushruta’s account of granthi formation does not fully explain the development of a pituitary tumor, it does suggest the kaphogenic development of a slow-growing tumor.
As a result of the benign pituitary tumor and increase in prolactin secretion, symptoms (rupa) follow that result in further kapha and vata vitiation in other dhatus and srotas, including:
Referring to kaphogenic diseases of the head, chapter 17, verses 24 - 25 of the Charaka Samhita states, “by sedentary habits, sleep during the daytime (when it is not desirable), excessive intake of heavy and unctuous food, the kapha of the head gets vitiated and causes head-disease.” 31 Considering the samprapti, the nidana of a benign tumor (arbuda/granthi) of the majja dhatu in the majjavaha srota includes:
Possible Vata Nidana
Likely Kapha Nidana
An arbuda/granthi of the majja dhatu in the majjavaha srota (benign, prolactin-secreting tumor of the pituitary gland) is difficult to cure, not only from a western medical perspective, but also from an Ayurvedic perspective. Prolactinoma potentially involves the vitiation of two doshas in the sixth dhatu layer (majja).28 According to Sushruta, a benign pituitary tumor is incurable. The Sushruta Samhita, Chapter 11, verses 17 - 18, volume two states,
As stated earlier, the pituitary gland resides in the cavity of the sella turcica.3 Indeed, some patients require lifelong, western pharmaceutical treatment in order to manage their prolactinoma.32
Despite the prognosis of ‘difficult to treat or cure’, and even potentially ‘incurable’, Ayurveda provides possibilities for cure, including approaches to tumor reduction and the management of prolactinemia. Sushruta (volume two, chapter 18, verses 28 - 40) presents an array of possibilities for the treatment of arbuda; however, all of the treatments presented call for external applications directly to the tumor.26 This approach is not applicable in the case of pituitary tumors.
As with any Ayurvedic treatment, the first step is to clear ama (toxicity) and regulate agni (digestive fire). If the patient is strong enough, the patient should undergo panchakarma (langhana chikitsa) to clear ama and alleviate excess kapha and vata doshas from the body. Following purvakarma, an emphasis of vamana, niruha and anuvasana basti, and nasya therapies should be considered. Nasya is likely to be a very effective therapy in order to remove vitiated doshas from the head. If a patient is not strong enough, a palliative approach to clear ama and regulate agni should be taken (shamana chikitsa).28
Following shodhana chikitsa (langhana or shamana chikitsa) and samsarjana krama, a variety of kapha-pacifying dietary, lifestyle, herbal and body therapies should be considered in the Ayurvedic treatment of prolactinoma. Care must also be taken to prevent vata vitiation.
In addition to directing treatment to emphasize tumor reduction (kapha pacification), the management of prolactin levels with dopaminergic herbs should also be a part of treatment if a patient is not managing prolactin with an integrative approach that includes western, dopaminergic drugs.
In order to reverse the nidana, a kapha-pacifying diet should be followed and include an emphasis on bitter and pungent tastes. A lifestyle including stable routines (to manage vata), no oversleeping, and exercise (including kapha-pacifying yoga asana) should be followed. Appropriate body therapies in addition to nasya may include medicated shiro basti and shirodhara using light oils, such as safflower. Abhyanga, along with anuvasana basti, will also be important for managing vata.
Aroma therapies may include the use of frankincense, which has been shown (boswellia sacra) to have anti-tumor properties.34 Other kapha-pacifying essential oils to consider include, myrrh, basil, wintergreen and cinnamon. Chromotherapies may include exposure to the kapha-vata reducing colors of yellow and green as well as the balancing effects of the color gold.28
Given Ayurveda’s comprehensive approach to treatment that addresses mind, body and spirit, other subtle therapies to be considered include daily meditation, visualization of a healthy pituitary gland and tumor shrinkage, alternate-nostril breathing for balancing nadi flow, and the chanting of all seven bija mantras (if the patient’s ojas is strong). The chanting of kshum (6th chakra bija mantra) to balance the ajna chakra may also be helpful due to the chakra’s connection to the hypothalamus and pituitary gland.28
Dr. David Frawley explains in Ayurvedic Healing that the herbal treatment for cancer should include all of the following categories of action: alteratives, circulatory stimulants, immune strengthening tonics, expectorants, and strong bitter or pungent herbs with fat-reducing and toxin-destroying properties.33 While prolactinoma is not regarded as cancerous,4 an herbal, anti-cancer approach should prove beneficial in efforts to reduce tumor size or growth. All of the herbal categories Frawley mentions have anti-tumor properties.36 Dr. A. A. Mundewadi is Chief Ayurvedic Physician at Mundewadi Ayurvedic Clinic based at Thane, Maharashtra, India. He states, “pituitary gland tumors (which secrete excess prolactin) may be treated with Kanchnaar Guggulu, Panch Tikta Ghruta Guggulu, Guduchi (Tinospora cordifolia), Amalaki (Emblica officinalis), Mogra (Jasminum sambac) and Musta (Cyperus rotundus).” 38 Given that symptoms of prolactinoma, such as amenorrhea, galactorrhea, and impotence are the result of the secreting pituitary adenoma, the focus of herbal treatment for prolactinoma should be placed on tumor reduction and managing prolactin levels. This is likely to be best achieved with micro-adenoms. Macro-adenoms may require western medical treatment depending on the severity of symptoms, such as headaches and vision changes from nerve compression.
In addition to a variety of kapha-pacifying, reducing herbs, the following herbs should be especially considered for tumor reduction:35, 36
Kanchanar Guggulu Formula
“Growths: Kañcanara guggulu is a specific for clearing all growths and fluid-based accumulations in the body. It specifically reduces swellings and lumps(soft/hard/palpable/fixed/moveable)by drying the excess kapha. It is a favoured formula used in cancer caused by excess kapha. Also consider it in anal fistulas,abscesses and chronic skin lesions.” - Sebastian Pole 35
The following herbs should be especially considered for inhibiting prolactin:35, 37, 39, 40, 41
Vitex (Chasteberry) (Agnus Castus)
Kappikacchu (Cowhage) (Mucuna pruriens–Semen)
While kappikacchu is dopaminergic and research show that it may have an inhibitory effect on prolactin, it is kapha increasing, so may not be ideal for prolactinoma. It may be better used for other hyperprolactinemia conditions.
Ayurveda, whether used as a complementary approach to the allopathic treatment of prolactinoma or as an alternative, offers the possibility of complete healing. This is especially true for those with micro-prolactinomas and moderate prolactin elevation. As a complementary approach, Ayurveda can support healing by reversing the nidana and alleviating vitiated kapha and vata while a patient stabilizes his or her prolactin levels with prescription drugs. As an alternative approach, Ayurveda offers another option to those who have adverse reactions to pharmaceutical medication, lack insurance, or simply refuse to use allopathic treatment. By addressing diet, sleep, daily routines, mediation, exercise, and other lifestyle choices, Ayurveda leaves no aspect of living unaccounted for. Everything we do, consume, think, speak, or say has an influence on our health and can either encourage disease or promote healing. The comprehensive, healing protocols of Ayurveda offer sufferers of prolactinoma a proactive role in their healing that goes beyond taking daily medication, getting yearly MRIs and hoping for the best.
Symptoms of prolactinoma and hyperprolactinemia -- nashta rakta (amenorrhea) or oligomenorrhea, inappropriate lactation (galactorrhea), shiro roga (headaches), vision changes, infertility, and/or low libido -- can result from various other causes. If these symptoms appear, especially together, a medical evaluation is required to confirm (or rule out) hyperprolactinemia and the presence and size of a secreting-pituitary adenoma. Due to the consequences of abnormally high prolactin levels (infertility, increased risk of osteoporosis, low libido, possible tumor growth), an integrative approach to care, combining allopathic and Ayurvedic medicine, should be taken in order to monitor prolactin levels and tumor size. Herbal management of prolactin may be tried for a period of time before a patient is put on cabergoline or another dopamine agonist while using Ayurvedic approaches to clear ama, restore agni and alleviate vitiated doshas to reduce tumor size.
Many questions remain to fully understand the cause and treatment of prolactinoma, including:
According to the Neuroendocrine Clinical Center at the Massachusetts General Hospital, “Autopsy studies indicate that 25 percent of the U.S. population have small pituitary tumors. Forty percent of these pituitary tumors produce prolactin, but most are not considered clinically significant. Clinically significant pituitary tumors affect the health of approximately 14 out of 100,000 people.” 42 While the number of those affected with prolactinoma is small, each individual life is significant and optimal health is a birthright for all, therefore, further research and contemplation is needed from both an allopathic and Ayurvedic perspective to more fully understand and better treat prolactinoma.
|PPM Sluggish Digestion & Nausea||A/A||Kapha||Kledaka||Rasa||Increase||Annavaha||Dipanas|
|MT Systemic Swelling||O||Kapha||N/S||Rasa||Increase||Rasavaha||Diuretics Diaphoretic|
|MT Lethargy & Pale||O||Kapha||N/S||Rakta||Increase||Raktavaha||Circulatory Stimulans|
|Growth of anterior pituitary adenoma||RMD||Kapha||Tarpaka||Majja||Increase||Majjavaha||Anti-tumor|
|Non-pregnancy related breast lactation||RMD||Kapha||
|Male breast tissue growth||RMD||Kapha||Avalambaka||
|Cholegogu, Lekhanas, Alteratives|
|PPM Constipation & Gas||A/A||Vata||Apana||Rasa||Decrease||Purishavaha||Laxatives Demulcents Carminative|
|MT Systemic Dryness||O||Vata||Vyana||Rasa||Decrease||Rasavaha||Demulcents|
|MT Feeling cold & fatigue||O||Vata||Vyana||Rakta||Decrease||Raktavaha||Circulatory Stimulants|
|Irregular and/or Absence of Menses, Low libido||RMD||Vata||Apana||
|Decrease||Shukravaha (Men) Artavaha||Emmenogogues Reproductive Tonics, Demulcents|
|MT Bone weakness (risk for osteoperosis||RMD||Vata||Apana||Asthi||Decrease||Asthivaha||Bone Tonics|
6 Fraioli F, Paolucci D, Dondero F, Spera G, Isidori A. “Prolactin secreting adenoma in man and the role of prolactin in spermatogenesis.” Journal of Endocrinological Investigation. 1980 Apr- Jun;3(2):155-61. http://www.ncbi.nlm.nih.gov/pubmed/7391522