Hyperprolactinemia Treatment & Management

Updated: Mar 16, 2018
  • Author: Donald Shenenberger, MD, FAAD, FAAFP; Chief Editor: George T Griffing, MD  more...
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Treatment

Medical Care

Direct treatment is geared toward resolving hyperprolactinemic symptoms or reducing tumor size. Patients on medications that cause hyperprolactinemia should have them withdrawn if possible. Patients with hypothyroidism should be given thyroid hormone replacement therapy.

When symptoms are present, medical therapy is the treatment of choice. Patients with hyperprolactinemia and no symptoms (idiopathic or microprolactinoma) can be monitored without treatment. Consider treatment for women with amenorrhea. In addition, duel energy radiographic absorptiometry scanning should be considered to evaluate bone density.

A study by Wu et al indicated that dopamine agonists can provide long-term management of invasive giant prolactinomas. The study, which had a mean 135.5-month follow-up period, found that patients on bromocriptine achieved long-term control of their disease with regard to tumor shrinkage and normalization of prolactin level. However, the investigators also determined that in patients under age 25 years, there was a tendency toward persistent hyperprolactinemia even with long-term dopamine agonist therapy. [11]

A study by Krysiak et al found that in women with mild hyperprolactinemia (serum prolactin levels of 25-50 ng/mL), daily treatment with 5-10 mg of bromocriptine alleviated sexual dysfunction. Following therapy, subjects’ scores on the Female Sexual Function Index questionnaire increased, with patients experiencing improvements in desire, arousal, lubrication, and dyspareunia. [12]

In cases of pharmacologic-induced hyperprolactinemia, an evaluation of the risk-benefit profile of the causative agent is imperative. Stopping the drug is ideal, but this may not be feasible. A good example would be in the schizophrenic patient in whom a single antipsychotic agent is the cause, but is keeping the patient’s psychoses under control. The cautious addition of a dopamine agonist may be considered.

The persistent hypogonadism associated with hyperprolactinemia can lead to osteoporosis. Baseline dual-energy x-ray absortiometry (DEXA) scanning is appropriate. Treatment significantly improves the patient's quality of life. If the goal is to treat hypogonadism only, patients with idiopathic hyperprolactinemia or microadenoma can be treated with estrogen replacement and prolactin levels can be monitored. [13]

Radiation treatment is another option. However, the risk of hypopituitarism makes this a poor choice. It may be necessary for rapidly growing tumors, but its benefits in routine treatment have not been shown to outweigh the risks. [14]

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Surgical Care

General indications for pituitary surgery include patient drug intolerance, tumors resistant to medical therapy, patients who have persistent visual-field defects in spite of medical treatment, and patients with large cystic or hemorrhagic tumors.

In patients with symptomatic prolactinomas who are either not responding to high doses of dopamine agonists or cannot tolerate the high doses necessary, transspenoidal surgery has been suggested as the best treatment. However, no controlled studies have evaluated the surgical outcomes in medically resistant tumors. [14]

A retrospective study of male patients by Andereggen et al indicated that in men with prolactinomas, impaired bone density remains a problem even after medical (dopamine-agonist) or surgical treatment. The two types of therapy each successfully controlled hyperprolactinemia and hypogonadism. However, at median long-term follow-up (63 mo), bone density pathology was found in 37% of patients, being high in both the medical and surgical cohorts, compared with 27% at baseline. [15]

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Consultations

Physicians who are comfortable with the initial evaluation of a patient (without evidence of tumor mass effect) can easily initiate therapy and provide follow-up. However, given the time constraints of modern ambulatory medicine, consultation with an endocrinologist is often necessary.

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