Do you ever check prolactin (Prolactin hormone) levels in the evaluation of postmenopausal bleeding?

Prolactin Testing in Postmenopausal Bleeding Evaluation

Prolactin testing is not indicated in the routine evaluation of postmenopausal bleeding, as there is no established relationship between prolactin levels and postmenopausal bleeding etiology.

Rationale for Not Testing Prolactin in Postmenopausal Bleeding

Evidence-Based Considerations

• Current guidelines do not recommend prolactin measurement as part of the standard workup for postmenopausal bleeding
• Prolactinomas are rarely diagnosed in postmenopausal women 1
• When prolactinomas do occur in postmenopausal women, they typically present with:
  • Large macroadenomas (mean size 25.6 ± 12.4 mm) 2
  • Visual field defects (common presenting symptom) 2
  • Very high prolactin levels (median 827 ng/ml) 2
  • Not with vaginal bleeding as a primary symptom

Appropriate Indications for Prolactin Testing

Prolactin measurement should be reserved for specific clinical scenarios:

1. Suspected pituitary disorders:

   • Visual field defects
   • Headaches suggestive of mass effect
   • Multiple pituitary hormone abnormalities

2. Specific hormonal evaluations:

   • When evaluating testosterone deficiency in combination with low/low-normal LH levels 3
   • In patients with symptoms of hyperprolactinemia (galactorrhea, even in postmenopausal women)

Proper Evaluation of Postmenopausal Bleeding

Recommended Approach

1. Transvaginal ultrasound to assess endometrial thickness

   • Endometrial thickness <4 mm has low risk of malignancy 4
   • Thicker endometrium warrants further evaluation

2. Endometrial sampling for histopathologic evaluation when indicated

   • Endometrial biopsy or dilation and curettage
   • Hysteroscopy for direct visualization when needed

3. Hormone evaluation if clinically indicated:

   • Estrogen and androgen levels may be relevant in some cases 4
   • Thyroid function tests if symptoms suggest thyroid dysfunction

Special Considerations

When to Consider Prolactin Testing in Postmenopausal Women

Prolactin testing should be considered in postmenopausal women with:

• Galactorrhea
• Visual field defects
• Headaches suggestive of pituitary mass
• Incidental pituitary lesion on imaging
• Unexplained hypogonadotropic hypogonadism

Prolactin in Postmenopausal Women

• Normal prolactin range in postmenopausal women: 2.0-20.0 ng/mL 5
• Physiologic decline in prolactin levels typically occurs after menopause 6
• Prolactinomas diagnosed after menopause are usually macroadenomas with high prolactin levels 7

Conclusion

Prolactin testing should not be included in the routine evaluation of postmenopausal bleeding. Focus should remain on appropriate endometrial assessment through imaging and tissue sampling to rule out endometrial hyperplasia and malignancy, which are the primary concerns in postmenopausal bleeding.