From the Guidelines
The next steps in primary care for a patient with hyperprolactinemia involve confirming the elevation with repeat testing, ruling out common causes, and considering referral to an endocrinologist for complex cases or large adenomas. Initial workup should include a comprehensive medication review, pregnancy test in women of childbearing age, thyroid function tests, and renal function assessment, as recommended by the consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence 1. A single prolactin measurement taken at any time of the day is sufficient to assess hyperprolactinaemia, but serial measurements over time may be necessary to exclude the effect of stress and prolactin pulsatility 1. Brain MRI with contrast is indicated to evaluate for pituitary adenomas, particularly if prolactin levels exceed 100 ng/mL. For symptomatic patients or those with macroadenomas, dopamine agonist therapy is the first-line treatment, typically starting with cabergoline 0.25 mg twice weekly, which can be gradually increased based on prolactin levels and symptom response, as recommended by the consensus guideline 1. Bromocriptine 1.25-2.5 mg daily is an alternative but has more side effects. Treatment goals include normalizing prolactin levels, restoring gonadal function, reducing tumor size if present, and alleviating symptoms like galactorrhea, menstrual irregularities, or sexual dysfunction. Regular monitoring of prolactin levels every 1-3 months initially, then every 6-12 months once stable, is essential. Dopamine agonists work by mimicking dopamine's inhibitory effect on prolactin secretion from the pituitary gland. Referral to an endocrinologist is appropriate for complex cases, large adenomas, medication intolerance, or treatment resistance, and radiotherapy may be considered in exceptional cases where other treatment modalities are not available or have been exhausted 1.
From the FDA Drug Label
The recommended dosage of cabergoline tablets for initiation of therapy is 0.25 mg twice a week. Dosage may be increased by 0. 25 mg twice weekly up to a dosage of 1 mg twice a week according to the patient's serum prolactin level. Before initiating treatment, cardiovascular evaluation should be performed and echocardiography should be considered to assess for valvular disease.
The next steps in primary care for a patient with hyperprolactinemia (elevated prolactin level) include:
- Cardiovascular evaluation before initiating treatment with cabergoline
- Consideration of echocardiography to assess for valvular disease
- Initiation of cabergoline therapy with a recommended dosage of 0.25 mg twice a week, with possible increases up to 1 mg twice a week based on serum prolactin level
- Periodic assessment of cardiac status and consideration of echocardiography every 6 to 12 months or as clinically indicated 2 2
From the Research
Next Steps in Primary Care for Hyperprolactinemia
The next steps in primary care for a patient with hyperprolactinemia (elevated prolactin level) involve several key considerations:
- Differential Diagnosis: It is essential to rule out other causes of hyperprolactinemia, such as drug intake, hypothyroidism, renal failure, cirrhosis, chest wall lesions, or idiopathic hyperprolactinemia 3, 4.
- Pituitary Imaging: If serum prolactin levels are above 200 microg/L, a prolactin-secreting pituitary adenoma (prolactinoma) is the likely underlying cause, and pituitary imaging with computerized tomography (CT) or magnetic resonance imaging (MRI) is necessary to define the presence of a lesion compatible with a pituitary tumor 3, 5.
- Medical Therapy: Dopamine agonists, such as bromocriptine, cabergoline, quinagolide, and pergolide, are the first-line treatment for prolactinomas, with cabergoline being a commonly used option due to its favorable profile and efficacy in normalizing prolactin secretion and shrinking tumor size 3, 4, 6.
- Treatment Objectives: The main objectives of treatment are to suppress excessive hormone secretion, remove the tumor mass, preserve residual pituitary function, and prevent disease recurrence or progression 6.
- Surgical and Radiotherapy Options: Surgical resection of the prolactinoma is considered for patients who do not respond to medical therapy or have persistent neurological signs, while radiotherapy may be used as a supportive treatment in cases where surgery fails or medical response is not achieved 3, 7.
- Follow-up and Monitoring: Regular follow-up with serial prolactin measurements and pituitary imaging is crucial to monitor the effectiveness of treatment and detect any potential complications or recurrence of the disease 3, 5.