From the Guidelines
Hyperprolactinemia in young females is primarily caused by medications, prolactinomas, hypothyroidism, stress, and pregnancy or breastfeeding, with medications being a common cause, particularly antipsychotics and antidepressants, as noted in recent guidelines 1. When evaluating hyperprolactinemia, it is essential to consider these potential causes and investigate them accordingly.
Potential Causes
- Medications: antipsychotics like risperidone and haloperidol, antidepressants such as SSRIs, and certain antihypertensives like verapamil can cause hyperprolactinemia 1
- Prolactinomas: benign pituitary tumors that secrete excess prolactin, may require MRI imaging for diagnosis, and can be treated with dopamine agonists like cabergoline, which has been shown to be effective in normalizing prolactin levels and reducing tumor size 1
- Hypothyroidism: leads to increased prolactin due to elevated TRH levels, so thyroid function tests should be checked, and treatment with thyroid hormone replacement may be necessary 1
- Stress: physical and psychological stress can raise prolactin levels through activation of the hypothalamic-pituitary axis, and serial measurements of prolactin levels over time may be necessary to exclude the effect of stress and prolactin pulsatility 1
- Pregnancy and breastfeeding: naturally increase prolactin to support milk production, so a pregnancy test should be performed when evaluating hyperprolactinemia 1
Diagnostic Approach
- Check medication history to identify potential causes of hyperprolactinemia 1
- Perform a pregnancy test to rule out pregnancy as a cause of hyperprolactinemia 1
- Assess thyroid function to identify hypothyroidism as a potential cause 1
- Consider pituitary imaging if other causes are ruled out, and prolactin levels are significantly elevated, as a single prolactin measurement taken at any time of the day is sufficient to assess hyperprolactinemia 1
Treatment
- Depends on the underlying cause of hyperprolactinemia, and may include medication adjustment, dopamine agonists for prolactinomas, or thyroid hormone replacement for hypothyroidism 1
- Cabergoline is the dopamine agonist of choice for treating prolactinomas, due to its longer half-life and greater affinity for the dopamine receptor, and has been shown to be effective in normalizing prolactin levels and reducing tumor size 1
From the Research
Causes of Hyperprolactinemia
- Physiological conditions such as pregnancy or lactation can cause high prolactin levels in females 2
- Pathological conditions, including gonadal dysfunction and infertility, can also lead to hyperprolactinemia 2, 3
- Pituitary tumors, such as micro- or macroprolactinomas, are a common cause of persistent hyperprolactinemia, accounting for almost 50% of cases 2, 3
- Medications, including anti-psychotics and antidepressants, can induce hyperprolactinemia 2, 4
- Idiopathic hyperprolactinemia accounts for 30-40% of cases 2
- Iatrogenic causes, such as certain medications, can also lead to hyperprolactinemia in adolescent and young girls 5
Specific Causes in Young Females
- Prolactinomas can cause mass compression of the optic chiasm and anterior pituitary gland or prolactin hypersecretion, leading to delayed puberty, primary or secondary amenorrhea, and/or galactorrhea in adolescent and young girls 5
- Physiological hyperprolactinemia can occur during pregnancy or lactation, but pathological hyperprolactinemia can have significant consequences, including osteoporosis and infertility 2, 3
- Antidepressant-induced hyperprolactinemia can occur, although the incidence is not well established and symptoms are rare 4