From the Guidelines
Prolactinomas typically present with symptoms related to elevated prolactin levels and local mass effects, including menstrual irregularities, infertility, decreased libido, and galactorrhea in women, and decreased libido, erectile dysfunction, and infertility in men. These symptoms are a result of the hormonal imbalance caused by the tumor, as well as the physical compression of surrounding structures 1.
Common Symptoms
- Menstrual irregularities (oligomenorrhea or amenorrhea) in women
- Infertility and decreased libido in both sexes
- Galactorrhea (inappropriate milk production) in women, and less commonly in men
- Headaches and visual disturbances (particularly bitemporal hemianopsia) due to compression of the optic chiasm
- Cranial nerve palsies, hypopituitarism (deficiency of other pituitary hormones), and rarely, cerebrospinal fluid leakage in larger tumors
Diagnosis and Treatment
Diagnosis involves measuring serum prolactin levels, with values typically proportional to tumor size, and confirming with pituitary MRI imaging 1. Cabergoline is the dopamine agonist of choice for treating prolactinomas, due to its longer half-life and greater affinity for the dopamine receptor. It has been shown to induce normalization of prolactin levels, tumour shrinkage, and resolution of symptoms in both adults and children with prolactinoma 1.
From the Research
Presentation of Prolactinomas
Prolactinomas can present with a variety of symptoms, including:
- Reproductive dysfunction
- Galactorrhea
- Male-factor infertility by producing hypogonadism 2
- Neurologic symptoms by mass effect in the sellar area, if the tumor is large 2
- Hypogonadism, which can lead to osteoporosis 2
- Acne and hirsutism 2
- Headache 2
Diagnostic Evaluation
The diagnostic evaluation of prolactinomas involves:
- Exclusion of other causes of hyperprolactinemia, such as pregnancy, primary hypothyroidism, numerous medications, and miscellaneous causes 2
- Performance of a head scan, preferably an MRI, to exclude a "pseudoprolactinoma" which would require surgery 2
- Determination of whether a patient with hyperprolactinemia has an indication for therapy, such as a macroprolactinoma, hypogonadism, infertility, significant galactorrhea, acne, hirsutism, or headache 2
Treatment Options
Treatment options for prolactinomas include:
- Medical therapy with dopamine agonists, such as bromocriptine, pergolide, and cabergoline, which are extremely effective in lowering serum prolactin, restoring gonadal function, decreasing tumor size, and improving visual fields 2, 3
- Combination treatment with cabergoline and octreotide LAR, which may be effective in some patients with dopamine-agonist resistant macroprolactinomas 4, 5
- Neurosurgical transsphenoidal resection, which may be necessary for patients who are unable to tolerate or are resistant to medical therapy, particularly if the patient has a large lesion jeopardizing the optic chiasm 2