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Jehangir Waqas
JAIDS Journal of Acquired Immune Deficiency Syndromes: January 2016
doi: 10.1097/01.qai.0000479701.54420.44
Abstract: PDF Only

Pituitary adenoma has been reported in patients treated with estrogen or transsexual male-to-female gender. Estrogen directly stimulates the cells of the lactotroph & this can lead to lactotroph hyperplasia & even prolactinoma. HIV is associated with an increase risk of adenomas such as prolactinoma. A 22-year old HIV transsexual male-to-female presented with breast tenderness & galactorhea. Previously, patient underwent a transgender procedure including breast & buttocks estrogen pellet implant. She took estrogen injections for 2 years. She was taking once a day regime of rilpivirine-emtricitabine-tenofovir. Breast exam revealed milk discharge from the right nipple with bilateral breast tenderness. Serum Prolactin was 1147 ng/ml. An MRI of the brain showed 2.5 × 2.2 × 2.3 cm suprasellar mass. Patient was diagnosed with Pituitary Macroadenoma & was treated with Cabergoline. 3 months later her serum Prolactin level decreased to 96 ng/mL. When prolactinoma is diagnosed in a patient with HIV infection & a transgender male-to-female, the question arises is prolactinoma an association of HIV or is secondary to estrogen exposure. Another challenge is when it comes to management of such patient as there have been significant interactions between antiretroviral & prolactinoma treatment drugs. Although there has not been a documented interaction between Cabergoline or & Rilpivirine. Rilpivirine like most other non nucleoside reverse transcriptase inhibitors such as Efavienz is metabolized through CYP isoenzyme system & may increase levels of Cabergoline by decreasing its metabolism leading to toxicity. In patients who have high viral load, it is better to start such patients on Efavienz- based regimens to suppress viral load before switching to Rilpivirine- based regime. In such patients using dopamine agonist can be a real challenge due to drug interactions.

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