What is the treatment for hyperprolactinemia (elevated prolactin levels)?

Treatment of Hyperprolactinemia

Dopamine agonists, particularly cabergoline, are the first-line treatment for hyperprolactinemia, with a starting dose of 0.25-0.5 mg/week and regular monitoring of prolactin levels. 1

Diagnostic Evaluation

Before initiating treatment, proper evaluation is essential:

• Measure prolactin levels (normal reference ranges):

  • Non-pregnant females: 3.0-30.0 ng/mL
  • Pregnant females: 10.0-209.0 ng/mL
  • Postmenopausal females: 2.0-20.0 ng/mL 1

• Rule out secondary causes:

  • Medication review (especially antipsychotics)
  • Pregnancy
  • Hypothyroidism
  • Renal failure
  • Stress

• Imaging studies:

  • MRI of the pituitary to identify potential prolactinomas

Treatment Algorithm

First-Line Treatment: Dopamine Agonists

1. Cabergoline:

   • Preferred agent due to superior efficacy and tolerability 1, 2
   • Starting dose: 0.25-0.5 mg/week 1
   • Advantages: Longer duration of action (once or twice weekly dosing), better side effect profile 3
   • Normalizes prolactin in over 80% of cases 4

2. Bromocriptine:

   • Alternative if cabergoline is not tolerated or contraindicated
   • Dosing: Usually given once or twice daily 3
   • Less well-tolerated than cabergoline 4

Monitoring During Treatment

• Prolactin levels: Check after initiating therapy and periodically thereafter
• For macroprolactinomas:
  • MRI after 3 months to verify tumor size reduction
  • Then after 1 year, yearly for 5 years, and once every 5 years if stable 4
• For microprolactinomas:
  • MRI after 1 year and then after 5 years 4
• Echocardiography surveillance:
  • Initial echocardiogram at treatment initiation
  • Yearly for patients receiving >2 mg/week cabergoline
  • Every 5 years if on ≤2 mg/week cabergoline 1

Special Considerations

Pregnancy

• Dopamine agonists should generally be discontinued during pregnancy unless there's risk of tumor expansion 1, 5
• For women with macroprolactinomas planning pregnancy, reduce tumor size with dopamine agonists before conception 6
• Close monitoring during pregnancy due to potential tumor growth 1

Resistant Cases

• If one dopamine agonist fails, try another 4
• For truly resistant cases, consider a standardized, individualized, stepwise, dose-escalating regimen of cabergoline 2
• Surgical intervention may be necessary for dopamine agonist-resistant cases 7

Drug-Induced Hyperprolactinemia

• If causative medication cannot be withdrawn, avoid dopamine agonists
• Consider sex steroid replacement to prevent osteoporosis 4

Safety Concerns

Cardiac Valvulopathy

• Risk primarily with high-dose cabergoline (>2 mg/day) used for Parkinson's disease 8
• Lower risk at doses used for hyperprolactinemia 2
• Regular echocardiographic monitoring recommended 1, 8
• Discontinue if valvular regurgitation, restriction, or thickening develops 8

Other Fibrotic Complications

• Monitor for pleural, pericardial, and retroperitoneal fibrosis, especially with long-term, high-dose treatment 8, 5
• Watch for symptoms like dyspnea, cough, chest pain, back pain, edema 8

Hypotension

• Can occur especially during initial treatment
• Exercise caution when driving or operating machinery 5

Treatment Duration and Discontinuation

• After achieving normal prolactin levels, consider reducing dose or attempting discontinuation
• Upon discontinuation, hyperprolactinemia recurs in only 20-30% of cases 4
• Continue monitoring prolactin levels after discontinuation
• Consider withdrawal of dopamine agonists in well-controlled patients, especially postmenopausal women 2

Surgical Management

• Reserved for specific situations:
  • Failure of medical therapy
  • Intolerance to dopamine agonists
  • Evidence of mass effect despite medical therapy 3
  • Transsphenoidal approach is preferred 7