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If pregnancy is desired in a woman with hyperprolactinemia, dopamine agonists are not approved during pregnancy and should be discontinued once pregnancy is confirmed, but their use is recommended if neurologic findings are present (1)[A].
With microprolactinoma: Treat with bromocriptine if symptomatic; monthly pregnancy tests; discontinue bromocriptine when pregnancy is confirmed.
With macroprolactinomas: a definitive, individualized plan is made. Options include discontinuation of bromocriptine at conception and careful monitoring of PRL levels and VS, with or without MRI scan evidence of tumor enlargement; prepregnancy transsphenoidal surgery with debulking of tumor; continuation of bromocriptine throughout gestation, with a risk to the fetus.
Careful monitoring of visual fields in each trimester. No need to monitor prolactin levels, as they are normally high due to pregnancy (1)[A].
PATIENT EDUCATION
- Discuss risks of untreated hyperprolactinemia:
- Headache
- Visual field loss
- Decreased bone density
- Infertility
- Patient guide to hyperprolactinemia diagnosis and treatment
PROGNOSIS
- Tends to recur after discontinuation of medical therapy (1)
- Over 10 years, 7% chance of progression of prolactin-secreting microadenoma (4)
COMPLICATIONS
- Depends on underlying cause
- If pituitary adenoma, risk of permanent visual field loss
REFERENCES
11 Hoffman AR, Melmed S, Schlechte J. Patient guide to hyperprolactinemia diagnosis and treatment. J Clin Endocrinol Metab. 2011;96(2):35A-36A.22 Wang AT, Mullan RJ, Lane MA, et al. Treatment of hyperprolactinemia: a systematic review and meta-analysis. Syst Rev. 2012;1:33.33 Wong A, Eloy JA, Couldwell WT, et al. Update on prolactinomas. Part 2: treatment and management strategies. J Clin Neurosci. 2015;22(10):1568-1574.44 Casanueva FF, Molitch ME, Schlechte JA, et al. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol (Oxf). 2006;65(2):265-273.55 Bloomgarden E, Molitch ME. Surgical treatment of prolactinomas: cons. Endocrine. 2014;47(3):730-733.66 Sun GE, Pantalone KM, Gupta M, et al. Is chronic nipple piercing associated with hyperprolactinemia? Pituitary. 2013,,16(3):351-353.
ADDITIONAL READING
- Inancli SS, Usluogullari A, Ustu Y, et al. Effect of cabergoline on insulin sensitivity, inflammation, and carotid intima media thickness in patients with prolactinoma. Endocrine. 2013;44(1):193-199.
- Inder WJ, Castle D. Antipsychotic-induced hyperprolactinaemia. Aust N Z J Psychiatry. 2011;45(10):830-837.
- Jackson J, Safranek S, Daugird A. Clinical inquiries. What is the recommended evaluation and treatment for elevated serum prolactin? J Fam Pract. 2006;54(10):897-899.
- Klibanski A. Clinical practice. Prolactinomas. N Engl J Med. 2010;362(13):1219-1226.
- Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(2):273-288.
- Molitch ME. Pituitary gland: can prolactinomas be cured medically? Nat Rev Endocrinol. 2010;6(4):186-188.
CODES
ICD10
E22.1 Hyperprolactinemia
ICD9
253.1 Other and unspecified anterior pituitary hyperfunction
SNOMED
- 237662005 hyperprolactinemia (disorder)
- 237668009 Pregnancy hyperprolactinemia (disorder)
- 237666008 Physiological hyperprolactinemia (disorder)
- 237665007 Drug-induced hyperprolactinemia (disorder)
- 237667004 Lactation hyperprolactinemia (disorder)
CLINICAL PEARLS
- If a cause for hyperprolactinemia cannot be found by history, examination, and routine laboratory testing, an intracranial lesion might be the cause and brain MRI with specific pituitary cuts and intravenous contrast media should be performed.
- Treatment of hyperprolactinemia should be targeted at correcting the cause (hypothyroidism, discontinuation of offending medications, etc.).
- There is a difference among antipsychotics in influencing prolactin levels. In general, those with the highest potency D2 antagonism are most likely to elevate prolactin levels. Among the newer atypical antipsychotics, risperidone has been identified as more likely to elevate prolactin.
- Chronic nipple piercing has not been shown to cause hyperprolactinemia (6).
- High prolactin levels decrease testosterone by inhibiting gonadotropin-releasing hormone (GnRH), LH, and FSH secretion and by decreasing central dopamine activity, both of which are important in mediating sexual arousal.