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© Thomson Reuters, Journal Citation Reports, 2016

Med Clin 2015;144:73-9 - DOI: 10.1016/j.medcle.2014.04.001
Special article
Endocrinologic diseases management during breastfeeding
Tratamiento de enfermedades endocrinológicas durante la lactancia
Pilar Serrano Aguayoa, Juan Manuel García de Quirós Muñozb,, , Irene Bretón Lesmesc, Maria Victoria Cózar Leónb
a Unidad de Endocrinología y Nutrición, IBCLC, Hospital Virgen del Rocío, Sevilla, Spain
b Unidad de Endocrinología y Nutrición, Hospital Virgen de Valme, Sevilla, Spain
c Unidad de Nutrición y Dietética, Hospital Gregorio Marañón, Madrid, Spain
Recibido 20 febrero 2014, Aceptado 24 abril 2014

Frequently, health care professionals have to treat endocrinological diseases in women during the breastfeeding period. There are many scientific spaces dedicated to the treatment of endocrinological diseases during pregnancy, in publications, seminars and congresses. However, there are not many reviews on the treatment of these diseases during the breastfeeding period. Sometimes, endocrinologists have little information on the subject, or search for information with special interest in sources that cannot be easily accessed, or scattered sources. It is not uncommon for endocrinologists to decide to suspend breastfeeding (BF) if they have doubts. Although these approaches vary according to the training of the professional, let us use Canada case as an example, where 44% of endocrinologists recommended suspending BF when treatment with antithyroid medication must be provided to a woman during breastfeeding.1

To obtain a proper answer, it is necessary to ask the right question. The immediate answer to the question “does this child need to take a certain amount of a certain drug?” is no. However, if we take into consideration all the aspects of a decision, the right question is: are the risks of taking milk from his mother with a certain amount of a certain drug more serious and frequent for this child than those of artificial feeding? What are the risks of giving up breastfeeding for this woman? In order to answer these questions, we must know the risks of artificial feeding and compare them with those of BF with a certain amount of the drug, as well as the risks of breastfeeding or giving up breastfeeding for a woman with a certain endocrinopathy. The purpose of this article is to provide information on those aspects.

Numerous research works document the advantages of BF for mothers, children, the family and society.2 That includes health, nutritional, immunological, psychological, social, economical and environmental benefits in the short, medium and long term.3 The advantages of BF are present both in poor and technologically advanced countries.4 Favouring a high rate of breastfeeding also implies large savings of health care resources.5

The World Health Organization and the Spanish Paediatric Association recommend exclusive BF until 6 months of age, and to continue BF, along with other foods, until the baby is at least 2 years old, with no maximum time, but as long as the mother and child want to continue.6

Prolactinoma

An effective treatment of hyperprolactinaemia restores fertility, and it is therefore of special interest for the management of prolactinoma during pregnancy and breastfeeding.

The probability of growth of microprolactinomas during pregnancy is very low, and 1.6–2.4% of patients show symptoms related to tumour growth (headache), although in some others (4.5%), an asymptomatic growth may be proved through imaging tests.7 For this reason, and given the potential teratogenicity of the drugs, we recommend suspending treatment with dopaminergic agents once the pregnancy is confirmed. The proper treatment if there are symptoms of tumour growth is bromocriptine. We do not recommend carrying out imaging or ophthalmologic tests in all cases, but only if the patient mentions symptoms evidencing tumour growth.8

As regards macroprolactinomas, 37% of cases present symptoms of tumour growth (headache, in general, and only in some cases, visual changes), and an additional 17% may present asymptomatic tumour growth, which can be proved through imaging tests. 34% of patients may experience a reduction of the tumour.9 Treatment with bromocriptine during the 12 months prior to the pregnancy greatly reduces the possibility of tumour growth, as well as having had previous pituitary surgery or radiotherapy.8,10 In most cases, the symptoms of growth are resolved with bromocriptine treatment, although in some cases, pituitary surgery is necessary. We recommend close clinical surveillance during pregnancy and performing imaging and visual tests if there were any symptoms of tumour growth, which, if confirmed, may be treated with bromocriptine, reserving surgery for cases not responding to this treatment. For certain tumour locations, it may be advisable to use bromocriptine without interruptions, since the beginning of the pregnancy, without waiting for symptoms of further tumour growth.10

After the pregnancy, there is frequently a decrease of prolactin levels (PRL), in relation to concentrations prior to the pregnancy, with normalisation at 60% of microprolactinomas and at 72% of macroprolactinomas.11 In an additional 11%, the tumour is healed (normalisation of prolactin and restored menstruation). The reduction or disappearance of the tumour occurs in 27–35% of cases.7

PRL measurement is not useful for a follow-up of microprolactinoma or macroprolactinoma during pregnancy or breastfeeding.8,12

BF was a concern in relation to potential tumour growth, because suction stimulates prolactin release. However, there is no evidence that BF poses a risk of tumour growth,13 probably because the doubtful effect of suction over tumour cells is non-existent and is lower than the effect of the oestrogen stimulus received during pregnancy, and because of the protection offered by hypoestrogenemia inherent to BF. BF does not increase the recurrence of hyperprolactinaemia, which is normalised in 68% of patients with prolactinomas (microprolactinomas and macroprolactinomas) or functional hyperprolactinaemia after pregnancy.14 Therefore, breastfeeding must be advised in all cases of prolactinoma. No differences have been observed either in prolactin concentrations after breastfeeding based on the duration of breastfeeding. In cases with complications during pregnancy, there must be a strict follow-up, but with no contraindication of breastfeeding initially. If there is compression of the optic chiasm or other adjacent structures, initiating treatment with a dopaminergic agonist will be recommended, and the side effect will be suppression of BF. The current consensus, according to the Pituitary Society guidelines for the diagnosis and treatment of prolactinomas, is that neither microprolactinomas nor macroprolactinomas with no compromise of space are an absolute or relative contraindication for BF.15 Treatment with dopamine agonists shall not be started until the end of BF. It is not adequate to advise the mother to stop breastfeeding before the rest of women, that is to say, BF until at least 2 years old, with no maximum. Meanwhile, a clinical follow-up will be performed, and if there is any suspicion of tumour growth, imaging tests shall be performed to confirm.

Diabetes mellitus

The known benefits of breastfeeding are of special interest in children of women with diabetes mellitus (DM), both type 1 and 2 (DM 2), because a reduction on the incidence of these diseases in susceptible patients has been reported.16–19 The longer duration of BF also protects mothers with gestational diabetes from DM 2: BF is associated with a marked delay in the onset of DM 220 and a notable minor incidence of said disease.21 The screening for DM 2 in women who have had gestational diabetes is recommended from week 6 to 12 after delivery.22 It is not advisable to suppress BF to perform the test, which has been the standard practice so far and is prejudicial to women, because it deprives women from an important factor of protection against the development of DM 2.

BF allows the mother to enjoy an option of health, such as breastfeeding, in the context of the overload caused by chronic diseases. Diabetic women have the capacity to breastfeed their children, like the rest of women. The American Diabetes Association recommends encouraging diabetic women to breastfeed.23

Considerations for the treatment of diabetes during breastfeeding

The frequency of complications in the delivery for diabetic women increases when the diabetes is not properly controlled. But even in well controlled patients, an excess of medical intervention leads to an increase in complications. A large number of diabetic women, regardless of their degree of metabolic control and the status of the foetus, have induced deliveries, which is associated with a higher rate of instrumented deliveries and caesarean sections. Frequently, the new-born is separated from the mother and admitted into the neonatal unit, many times for observation only. Very often, the new-born receives dextrose solution or artificial formula to avoid potential hypoglycaemia (the incidence of which is increased in children of diabetic women, especially if they did not have a proper metabolic control), therefore omitting the first step of prevention, which is frequent breastfeeding and skin-to-skin contact with the mother.24 All of that leads to a delay of the first contact with the breast, which is the most important factor for successful breastfeeding, also for diabetic women.25 In conclusion, diabetic mothers have more obstacles in the beginning of breastfeeding than non-diabetic mothers, and their breastfeeding may be easier if the circumstances benefiting the success of BF for any mother–child are ensured. Diabetes itself is not an obstacle to BF, and the factors associated with failure of same are the same than those for non-diabetic women.26 Together with the general information on breastfeeding that the mother should receive during the pregnancy, it may be useful to add information regarding breastfeeding in the event of caesarean section and separation of the new-born. Providing the additional support that diabetic mothers may require is associated to a higher rate of successful breastfeeding.27

The excretion of lactose in urine (lactosuria) is a fact at the end of the pregnancy and the first days of the puerperium, until the child takes a good amount of milk, and also when the production of milk exceeds what the child takes. It may lead to a diagnosis error in diabetic women, because it can be detected as glucose in urine28 when reagent strips are used.

Insulin needs decrease in relation to those prior to pregnancy,29 and it is therefore important to pay attention to capillary blood sugar levels monitoring, adjust the insulin dose and make adjustments in the diet. It is practical to advise the mother to have a snack available to eat when she notices symptoms of hypoglycaemia, which are more frequent during breastfeeding and shortly after.

Breastfeeding diabetic mothers must take into consideration the increase in the requirement of nutrients, just like any other breastfeeding women. The distribution of food during the day is important, to anticipate potential hypoglycaemia during the child's feeding, or shortly after, which also requires adjustments in the insulin dose. The beginning of supplementary feeding and delactation require new adjustments in the diet and insulin, which must be made individually.

Lactogenesis and the let-down reflex may be delayed due to independent factors to the delay in the first contact with the breast and less frequent suction.30

Compatibility of commonly used drugs to treat diabetes with breastfeeding

The American Academy of Paediatrics (AAP) has periodically published guidelines on the compatibility of drugs with BF to help doctors in the decision making. Until 2001, these guidelines consisted of lists of drugs classified according to their potential effects on breastfeeding or the child, and the longest one was the list of drugs usually compatible with BF. In the last edition of 2013,31 it recommends assessing each case individually, based on the more extensive and permanently updated information, available through LactMed,32 an Internet database included in TOXNET, of National Library of Medicine of the U.S.A.

  • 1.

    Insulin: a large peptide that does not get to the milk, and even if it did, it would be destroyed in the child's gastrointestinal tract.33 It poses no risks for the infant (Table 1).

    Table 1.

    Compatibility of the most used drugs for diabetes mellitus with breastfeeding.

    Insulin  Compatible. It is destructed in the gastrointestinal tube of the infant 
    Sulphonylureas
    Tolbutamide  Compatible with breastfeeding 
    Glibenclamide glyburide and glipizide  Compatible with breastfeeding 
    Glimepiride  There are no data in humans, it is significantly transferred to milk in rodents. It is best to avoid it 
    Other sulfonylurea  There are no data 
    Thiazolidinediones (pioglitazone and rosiglitazone)  There are no data in humans 
    Meglitinides (repaglinide and nateglinide)  There are no data in humans. It is significantly transferred to milk in rodents. It is best to avoid it 
    Biguanides: metformin  Compatible with breastfeeding 
    Alpha-glucosidase inhibitors (miglitol and acarbose)  Compatible with breastfeeding 
    DPP-4 inhibitors  There are no data 
    GLP-1 analogues  There are no data, but they have elevated molecular weight and join proteins with binding affinity. There is no oral bioavailability for the infant. The effects on the infant are unlikely 
    Calcium antagonists: nifedipine, diltiazem, verapamil.  Compatible with breastfeeding 
    ACE inhibitors: captopril, enalapril  Compatible with breastfeeding 
    Alfametildopa  Safe 
    Propranolol, labetalol, metoprolol  Compatible with breastfeeding 
    Atenolol  Not safe 
    Clopidogrel and ticlopidine  Not safe 
    Acetylsalicylic acid  Compatible with breastfeeding in small doses (antithrombotic) 
    Statins  There are no data 
    Resins  Compatible with breastfeeding 
    Fibrates  There are no data 
    Ezetimibe  There are no data 

    DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide-1; ACE inhibitor, angiotensin-converting enzyme inhibitor.

  • 2.

    Antidiabetic medication:

    • a)

      Sulphonylureas: Tolbutamide is considered safe and the AAP includes it in the list of medications compatible with breastfeeding.34 Glibenclamide (or glyburide) and glipizide are not significantly transferred to the milk, and there have not been hypoglycaemias in the children studied. Therefore, it is also considered compatible with breastfeeding.35 There are no data on humans regarding glimepiride, but studies on rodents have demonstrated the significant transfer to milk, and elevated plasma levels in offspring. Therefore, it is better to avoid it. There are no data regarding the remaining drugs.

    • b)

      Thiazolidinediones (pioglitazone and rosiglitazone). There are no data in humans.

    • c)

      Metiglinides (repaglinide and nateglinide). There are no data in humans. Studies in animals show that they can be transferred to the milk and induce hypoglycaemia in the offspring.

    • d)

      Biguanides: Metformin is considered safe. It is transferred to the milk in a clinically insignificant amount.36

    • e)

      Peptide analogues similar to glucagon-like-peptide 1: exenatide and liraglutide. There are no studies on humans. However, their pharmacokinetic characteristics make it less likely for them to cause undesirable effects on breastfed children. They are peptides with high molecular weight, and therefore scarce transfer to breast milk can be expected. To achieve their therapeutic effect, they require subcutaneous route,37 since they are destructed in the digestive tract (also the child's, assuming there were significant amount in the breast milk, which is highly unlikely). In mice, the transfer of exenatide to milk is scarce, according to the manufacturer's data sheet. In addition, liraglutide joins plasma proteins, making it improbable to be transferred to milk in significant amounts.

    • f)

      There are no data published for dipeptidyl peptidase inhibitors.

    • g)

      Acarbose: only 2% of the dose is absorbed in the mother's gastrointestinal tube, which makes it improbable for the drug to reach the child through the milk.

    • h)

      Miglitol: There are limited data indicating that it is scarcely excreted in milk (according to the manufacturer, 0.02 of a 100mg dose) and it is improbable that it affects the child.

  • 3.

    Calcium antagonists: diltiazem, verapamil, nifedipine, nicardipine. Its transfer to milk is insignificant. The AAP includes them in the list of medications compatible with breastfeeding.34

  • 4.

    Angiotensin converting enzyme inhibitors: enalapril, captopril. Its transfer to milk is scarce, but given the extreme sensibility of the neonatal kidney, its use in the first month of life is not advisable. The AAP includes them in the list of medications compatible with breastfeeding.

  • 5.

    Alfametildopa: It is transferred to the milk in insignificant amounts. The AAP includes them in the list of medications compatible with breastfeeding.

  • 6.

    Beta blockers: propranolol, labetalol and metoprolol are considered compatible with breastfeeding. Acebutolol and atenolol, for which hypotension and bradycardia in infants has been described, are not compatible.

  • 7.

    Antiplatelets:

    • a)

      Acetylsalicylic acid is considered as posing some risk in the classification of the AAP, although it must be noted that studies carried out and the effects described in infants have been obtained with high doses of salicylate, and it is unlikely that low doses of antiplatelets cause problems in infants. However, there are no dose–response studies, and since Reye's syndrome may appear with low doses of acetylsalicylic acid, its use cannot be recommended for breastfeeding women.

    • b)

      Clopidogrel and ticlopidine: these are drugs considered “not so safe” during breastfeeding.33 There are no data on its transfer to milk, and although no adverse events have been described in infants, they are powerful and irreversible platelet aggregation inhibitors. Thus, small quantities in the milk could, in theory, have lasting effects on infants. Therefore, the decision to use one of these drugs, instead of acetylsalicylic acid, must be made with caution and carefully assessing the risk/benefit ratio, until we have more data to help us with the decision-making on the subject.

  • 8.

    Hypolipidemic agents:

    • a)

      Statins: there is no relevant information on the use of these drugs during breastfeeding. There is only some information published on pravastatin,38 and although the levels in milk are low, the generalised consensus is that due to the possibility of altering the child's lipid metabolism, statins should not be used during breastfeeding.

  • 9.

    Resins (cholestiramine, colestipol). Since they are not absorbable by the gastrointestinal tube of mother, they do not transfer to the milk and, therefore, they are compatible with breastfeeding. It should be taken into consideration that prolonged use may favour the deficit of fat-soluble vitamins in the mother.

  • 10.

    Fibrates: there are no data published on its use during breastfeeding.

  • 11.

    Ezetimibe: there are no data published on its use during breastfeeding.

Thyroid alterationsHyperthyroidism

Treatment with antithyroid drugs, such as propylthiouracil and methimazole, is considered safe during breastfeeding.39 Both drugs are transferred to milk in small quantities. However, according to the latest data on hepatotoxicity with antithyroid drugs, especially propylthiouracil, it seems better to treat hyperthyroidism during breastfeeding with thioamides with the lowest possible dosage. In any case, as we say, both are compatible with breastfeeding, and there is no justification in withdrawing breastfeeding to begin treatment with antithyroid drugs, or advising against breastfeeding to a mother who already needs them during pregnancy. The risk to which the child would be exposed to with artificial breastfeeding is clearly higher than the risk of the use of these drugs by the mother. The thyroid function and the intellectual development of children remain normal during the treatment of their mothers. Even when the mother gets hypothyroidism caused by these drugs, the thyroid function in the child remains normal.40 Maternal doses of metimazol (tiamazol) of up to 20mg/day are considered safe both on the short (hormonal levels) and long term (psychomotor development).39,40

With doses above 20mg, taking the drug just after breastfeeding and before the longest sleep period of the child (for instance, after the night feeding) would minimise the exposure of the infant to the drug. With higher doses, in any case, a thyroid hormones determination could be made on the child to continue with breastfeeding.

Hypothyroidism

Typical symptoms of hypothyroidism are fatigue, somnolence, feeling cold, constipation, anaemia; in moderate or mild hypothyroidism, they may go unnoticed, because they are non-specific. During the puerperium, it may be confused with postpartum depression, or simply with fatigue attributed to the delivery or care of a new-born. In breastfeeding women, in addition to all of the above, it may cause a decrease in the production of milk, sometimes as the only symptom. Therefore, if there is suspicion of true hypogalactia, it is advisable to rule out the presence of hypothyroidism. This is the extended belief among professionals treating breastfeeding couples. The participation of thyroid hormones in the synthesis of milk is well-known. However, there are few medical publications documenting the effects of the thyroid function on the production of milk.41

Treatment consists of the administration of thyroxine sodium at replacement doses, which allow the mother to have normal concentrations of thyroid hormones. The thyroid hormone is present in the milk of healthy women in small amounts.42 Its exogenous administration also allows this transfer to the milk, also in small quantities, so reduced that they would not be enough to treat a child suffering from hypothyroidism. Therefore, treatment with thyroxine at replacement doses is considered safe during breastfeeding.

It is important to remember that women with hypothyroidism frequently require an increase in the regular dose of thyroxine during pregnancy, and a decrease of the dose prior to gestation, after the delivery. It is recommended to go back to the dose prior to the pregnancy after delivery, without waiting for a determination of hormone levels, and afterwards adjust the dose based on successive determinations.

Thyroid disease with onset during puerperium

It is treated individually because, frequently, women with previous unknown thyroid disease may develop it during the puerperium, which affects her health and her child's health, and it is important to take into consideration its diagnosis and treatment.

Postpartum thyroiditis

It is considered as a variant of Hashimoto's thyroiditis which appears within the first year after delivery. It affects 3–16% of women43 and up to 25% of women with type 1 DM.44 The course is variable. There may be a phase of temporary hyperthyroidism (not always present), sometimes followed by temporary hypothyroidism or, more rarely, permanent. It may also appear with these phases in women with hypothyroidism due to previous Hashimoto's thyroiditis, and in treatment with thyroxine, if there is some non-destructive thyroid. Most women do not require treatment. Only women with more prominent symptoms of hyperthyroidism will require symptomatic treatment, only with beta blockers (propranolol, labetalol or metoprolol, all compatible with breastfeeding45) and no antithyroid drugs. If there were a postpartum thyroiditis with hypothyroidism during breastfeeding, treatment with levothyroxine is indicated. After 6 months of replacement treatment, withdrawal may be attempted, provided it has been proved that the patient will not be hypothyroid.46

Graves’ disease with onset during puerperium

Hyperthyroidism is usually more symptomatic than postpartum thyroiditis, with higher hormonal concentrations, more enlargement of the thyroid gland, and it may be accompanied by Graves’ ophthalmopathy, absent in thyroiditis. A thyroid scintigram is not necessary in the differential diagnosis between both entities, which would also require temporary suspension of BF (Table 2). The differential diagnosis can be made based on clinical and hormone data. In some cases, it may not be easy initially, but reassessing the patient in 3 or 4 weeks we can have sufficient data to differentiate them. Hyperthyroidism of thyroiditis is usually improved, while Graves’ disease would have worsened or have no changes. The levels for thyroid-stimulating antibodies are increased in Graves’ disease, but not in thyroiditis.

Table 2.

Differential diagnosis of postpartum hyperthyroidism.

Graves-Basedow  Postpartum thyroiditis 
Clinical symptoms of evident (florid) hyperthyroidism  Usually not very symptomatic 
More elevated hormonal levels  Less elevated hormonal levels 
Potential Graves’ ophthalmopathy  Absent ophthalmopathy 
Increased TRAb levels  Non-increased TRAb levels 
No improvement after 4 weeks  Improvement after 4 weeks 

TRAb, thyroid releasing antibody.

Use of radioisotopes during breastfeeding47

The use of radioisotopes in breastfeeding women (Table 3) may require a temporary or definitive cessation of breastfeeding, depending on the dose and the isotope used, to avoid exposing the child to radioactivity through the milk. If there are diagnostic or therapeutic alternatives to the use of radioisotopes, it would be preferable to use them, or, if possible, delay the use the radioisotope (for instance, waiting until the end of breastfeeding for a definitive treatment of hyperthyroidism with I-131, and meanwhile, treating with antithyroid medication, if necessary). If it were really necessary, a detailed list of times where it is recommended not to breastfeed is provided in Table 4. During these periods, the mother can extract the milk and discard it, to maintain proper production of milk, or save it and give it to the child later, after 10 half lives of the radioisotope have passed. If possible, extracting the milk beforehand would allow disposing of milk to feed the child during the period while direct breastfeeding is not recommended.

Table 3.

Use of radioisotopes during breastfeeding.

Thyroid scintigram (seek for alternatives in diagnostic uses)  Tc99m allows for a temporary interruption of breastfeeding (according to the dose). I-131 contraindicated 
Hyperthyroidism treatment with I-131  I-131 contraindicated. Assess therapeutic alternatives 
Treatment of thyroid cancer with I-131a  Breastfeeding contraindicated after the administration of iodine (for this child, not for successive breastfeeding) 

I-131: iodine 131; m Tc99: metastable technetium-99.

a

In general terms, in the vast majority of cases there would be no inconvenience in delaying the treatment with radioactive iodine for approximately 6 months after the thyroidectomy surgery, especially if the differentiated thyroid carcinoma is of low risk (according to the 2009 Clinical Practice Guideline of the American Thyroid Association), and therefore the child will receive exclusive breastfeeding in these first few months.

Table 4.

Periods of interruption of breastfeeding with technetium-99m.

Technetium-99m dose  Period of interruption of BF 
30mCi  24
12mCi  12
5mCi (usual dose in diagnosed thyroid scintigrams)  4

BF, breastfeeding.

Source: United States Nuclear Regulatory Commission.47

After the use of usual clinical doses, it is not necessary for the mother to avoid close physical contact with her child.

Iodine deficit

The needs of the child exclusively fed with breast milk must be provided by his mother's milk. With a milk intake of 150–200ml per kilo of weight a day, the concentration of iodine in milk shall be at least 100μg/l to provide the 90μ/kg/day of the iodine that the child needs. The concentration of iodine in breast milk mainly depends on the mothers’ iodine intake, although the mammary gland has the capacity to make an active excretion and increase its concentration trying to ensure proper contribution, even when there is an iodine deficiency.

To obtain an iodine concentration in breast milk above 100μg/l, the iodine estimated need for breastfeeding women is at least of 250μg/day.48 In areas with iodine deficiency, these special needs are not guaranteed with iodine-rich food, such as iodised salt, and it is recommended that the breastfeeding woman receives an additional supplement with at least 200μg of iodine a day in the form of potassium iodide with a pharmacological formulation.49

Prolactin deficit

Prolactin is essential for lactogenesis, and its deficiency leads to postpartum agalactia. It is usually presented in association with other pituitary deficiencies. The most frequent causes are the destruction of the pituitary gland due to trauma, inflammation, tumours, surgery, radiation or infarction. The diagnosis is usually known before a potential pregnancy, which is usually not possible spontaneously. Only in the event of isolated prolactin deficiency, or onset of the deficiency during pregnancy, delivery or puerperium, a diagnosis would have to be made after the insufficient milk production appears. This scenario is typical for Sheehan's syndrome, and it is possible in lymphocytic hypophysitis (which does not always lead to prolactin deficiency).

Sheehan's syndrome

This is the name given to an infarction of the pituitary gland due to a severe loss of blood during or after delivery.50 Despite the higher obstetric control in our area, these cases still continue to exist. It may be recognised in the first days after delivery due to symptoms as lethargy, anorexia, weight loss and agalactia. Later, there is a lack of menstruation and loss of body hair. There are less severe forms that cannot be recognised until several years later. Cases have been described which keep some of the hormones produced by the pituitary gland. But the prolactin deficit is constant, which leads to failure in the production of milk.

Lymphocytic hypophysitis

It is a rare disease characterised by lymphocyte infiltration of the pituitary gland, followed by destruction of pituitary cells. A large proportion of cases occur at the end of the pregnancy or during the puerperium.51 The symptoms are headache and pituitary function deficit; the hormones which are most frequently at deficit are the adrenocorticotropic hormone (ACTH) and the thyroid-stimulating hormone. Sometimes there is hyperprolactinaemia, but other times there is prolactin deficiency.52

Isolated prolactin deficiency

Isolated prolactin deficiency53 is a rare entity with first clinical manifestation in the puerperium, and it is agalactia. Some of the cases described are associated with mutations of the genes Pit-1 and Prop-1.54,55 Sometimes it is associated with ACTH deficiency.

When there is prolactin or oxytocin deficiency, BF is not possible. Synthetic prolactin was obtained for the first time in 1990. Its exogenous administration restores BF in women with prolactin deficiency.56 There are synthetic hormones available in the market to replace each one of the hormonal deficits, except prolactin, which, despite having been isolated and synthesised, is not available for clinical use.

Funding

The authors declare that they received no funding to carry out this work.

Conflict of interest

The authors declare that there are no conflicts of interest.

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Please cite this article as: Serrano Aguayo P, García de Quirós Muñoz JM, Bretón Lesmes I, Cózar León MV. Tratamiento de enfermedades endocrinológicas durante la lactancia. Med Clin (Barc). 2015;144:73–79.

Corresponding author. (Juan Manuel García de Quirós Muñoz jamqir@gmail.com)
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