pituitary adenoma/prolactin secreting (prolactinoma)
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Epidemiology
- most common functional pituitary tumor
Pathology
- women
- almost always small tumors (microadenomas)
- clinical course is benign
- tumors rarely enlarge
- men
- generally large tumors (macroadenomas)
- often aggressive tumors
Genetics
- associated with defects in AIP
Clinical manifestations
- women
- oligomenorrhea
- galactorrhea in 1/3 of patients
- hirsuitism
- men
- erectile dysfunction
- gynecomastia not necessarily present[1]
- galactorrhea not necessarily present[1]
- both sexes
- infertility
- decreased libido
- signs/symptoms of sella tursica mass effect
- new-onset headache
- visual impairment
- visual field defects
- osteopenia
Laboratory
- serum prolactin
- elevated with prolactinoma; > 200 ng/mL confirms diagnosis
- if < 200 ng/mL, also consider hypothyroidism
- need both serum TSH & serum free T4 to rule out hypothyroidism[1]
- serum testosterone (8 AM) low
- serum LH low
- serum FSH low
- serum ferritin normal
Diagnostic procedures
- formal visual field testing each trimester[1]
Radiology
Complications
- prolactinomas may increase in size in pregnant women resulting in visual field loss[1]
Differential diagnosis
Management
- microprolactinomas in asymptomatic patients may be observed[1]
- women
- dopaminergic agonist*
- cabergoline preferred agent[1]
- carbergoline 0.25 mg twice weekly
- bromocryptine 5-10 mg PO QD
- treat when fertility is the goal
- cabergoline preferred agent[1]
- surgery
- prolactinomas not responding to dopaminergic agonist[1]
- most patients treated surgically relapse
- overall surgical mortality is 1%
- 50% of prolactinomas recur after resection[1]
- treat with birth control pills between pregnancies to ensure effective contraception, normal menses & skeletal integrity
- dopaminergic agonist*
- men
- bromocryptine*
- cabergoline*[1]
- trans-sphenoidal surgical resection
- reserved for patients who fail bromocryptine
- risk of morbidity & mortality
* dopaminergic agonists decrease size of prolactinomas > 50% in 80-90% of patients[1]
- initial management of prolactinoma with suprasellar extension & compression against the optic chiasm is dopamine agonist therapy[4]
More general terms
Additional terms
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Klibanski A Clinical practice. Prolactinomas. N Engl J Med. 2010 Apr 1;362(13):1219-26 PMID: https://pubmed.ncbi.nlm.nih.gov/20357284
- ↑ Mann WA Treatment for prolactinomas and hyperprolactinaemia: a lifetime approach. Eur J Clin Invest. 2011 Mar;41(3):334-42.
- ↑ 4.0 4.1 NEJM Knowledge+
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) web page "Prolactinoma" http://www.niddk.nih.gov/health/endo/pubs/prolact/prolact.htm