hyperprolactinemia
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Etiology
- prolactin-secreting pituitary adenoma
- pituitary stalk effects:
- non functioning pituitary tumors
- growth hormone secreting tumors may co-secrete prolactin
- lymphocytic hypophysitis
- empty sella syndrome
- Cushing's disease
- ACTH-secreting pituitary adenomas may co-secrete prolactin
- pituitary stalk compression[3]
- extra-pituitary lesions
- neurogenic
- chest wall or spinal cord disease
- breast stimulation
- breast lesions
- pharmacologic agents
- antipsychotic agents
- other dopaminergic antagonists
- antidepressants
- antihypertensive agents
- anticonvulsants[3]
- cimetidine[3]
- opiates[3]
- antiretroviral protease inhibitors[3]
- estrogen in usual doses does NOT cause hyperprolactinemia
- other
- hypothyroidism[3]
- pregnancy, lactation
- chronic renal failure (decreased prolactin clearance)
- cirrhosis
- macroprolactinemia (decreased prolactin clearance)
- adrenal insufficiency
- ectopic secretion
- psychophysiologic stimulation
- coitus
- nipple stimulation
- strenous exercise
- stress
- idiopathic
Pathology
- disruption of dopaminergic tuberoinfundibular system inhibition on prolactin secretion by pituitary lactotrophs
Clinical manifestations
- women
- oligomenorrhea
- galactorrhea in 1/3 of patients
- hirsuitism
- men
- erectile dysfunction
- gynecomastia not necessarily present[3]
- galactorrhea not necessarily present[3]
- both sexes
- infertility
- decreased libido
- headache
- osteopenia
Laboratory
- serum prolactin
- normal 0-23 ng/mL
- value > 200 ng/mL confirms prolactinoma vs antipsychotic as etiology
- value < 200 ng/mL when due to hypothyroidism[3]
- antipsychotics can cause values > 200 ng/mL
- value of 100 ng/mL may be due to prolactinoma[3]
- pregnancy test in women of child-bearing age with modestly elevated serum prolactin
- serum TSH with reflex to free T4*
- ref[7] suggests macroprolactin in serum for asymptomatic hyperprolactinemia but does not consider how this will change management
* hypothyroidism is a cause of hyperprolactinemia
Radiology
- pituitary MRI to assess for prolactinoma*[3]
* diagnosis prior to treatment
Management
- discontinue medications that can cause hyperprolactinemia & remeasure serum prolactin
- observation for women with microprolactinoma & normal menses[3]
- treat disorders associated with hyperprolactinemia & remeasure serum prolactin
- assess for hypothyroidism prior to dopaminergic agonist[3]
- dopaminergic agonists
- cabergoline[3]
- cabergoline is the preferred agent for treatment of prolactinoma in women
- bromocryptine (Parlodel) 2.5 mg PO QD
- preferred agent in men
- dopaminergic agonists
- inhibit prolactin secretion & serum prolactin
- decrease size of prolactinomas > 50% in 80-90% of patients[3]
- consider cessation of dopaminergic agonist when
- serum prolactin has normalized for >= 2 years
- prolactinoma is no longer visible[3]
- dopaminergic agonists can induce psychosis in patients taking antipsychotics
- cabergoline[3]
- trans-sphenoidal surgical resection of prolactinoma for patients who fail dopaminergic agonist[3]
- patients with primary hypothyroidism should be treated with thyroxine then retested (serum prolactin) once serum TSH has normalized[3]
- patient education: fertility in women can be achieved through use of bromocryptine
More general terms
More specific terms
Additional terms
- pituitary adenoma/prolactin secreting (prolactinoma)
- prolactin in serum
- prolactin; lactogenic hormone (PRL)
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 389
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 276
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL et al Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Feb;96(2):273-88. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21296991 corresponding NGC guideline withdrawn Feb 2017
- ↑ Mann WA Treatment for prolactinomas and hyperprolactinaemia: a lifetime approach. Eur J Clin Invest. 2011 Mar;41(3):334-42. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20955213
- ↑ Peuskens J, Pani L, Detraux J, De Hert M. The effects of novel and newly approved antipsychotics on serum prolactin levels: a comprehensive review. CNS Drugs. 2014 May;28(5):421-53. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24677189 Free PMC Article
- ↑ 7.0 7.1 NEJM Knowledge+ Endocrinology