From the Guidelines
For a 28-year-old female with an elevated prolactin level, I strongly recommend confirming the result with a repeat measurement, preferably in the morning after fasting and avoiding breast stimulation, to rule out stress-related hyperprolactinaemia, as suggested by 1. This approach is crucial because prolactin secretion can rise in response to stress, and a single measurement may not accurately reflect the patient's condition.
Key Considerations
- 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, as noted in 1.
- The diagnosis of hyperprolactinaemia requires age-specific and sex-specific prolactin reference ranges and the exclusion of confounding conditions such as hypothyroidism, renal and/or hepatic impairment, and use of medications that cause hyperprolactinaemia, as emphasized in 1.
- If hyperprolactinemia is confirmed, a pituitary MRI should be obtained to rule out a prolactinoma or other sellar lesions, and treatment depends on the cause and symptoms.
Treatment Options
- For symptomatic patients with microadenomas or idiopathic hyperprolactinemia, cabergoline is the first-line medication, typically starting at 0.25 mg twice weekly and titrating up as needed to normalize prolactin levels, as recommended in 1.
- Bromocriptine is an alternative at 1.25-2.5 mg daily initially, but has more side effects, and dopamine agonist therapy often requires long-term treatment with periodic attempts to reduce or discontinue medication to assess for remission.
Monitoring and Management
- Regular monitoring of prolactin levels every 1-3 months initially, then every 6-12 months once stable, is essential for proper management, and side effects such as nausea, dizziness, and headache can be minimized by starting with low doses taken with food and at bedtime.
- Treatment goals include restoring normal menses, fertility, and sexual function while reducing galactorrhea if present, and cabergoline has been shown to be effective in achieving these goals, as noted in 1.
From the FDA Drug Label
Hyperprolactinemic States Visual field impairment is a known complication of macroprolactinoma. Effective treatment with bromocriptine mesylate leads to a reduction in hyperprolactinemia and often to a resolution of the visual impairment In some patients, however, a secondary deterioration of visual fields may subsequently develop despite normalized prolactin levels and tumor shrinkage, which may result from traction on the optic chiasm which is pulled down into the now partially empty sella In these cases, the visual field defect may improve on reduction of bromocriptine dosage while there is some elevation of prolactin and some tumor re-expansion.
The significance of elevated prolactin levels in a 28-year-old female is that it may be associated with hyperprolactinemia, which can cause visual field impairment due to macroprolactinoma. Elevated prolactin levels can also be associated with amenorrhea, galactorrhea, and infertility.
- Key points:
- Elevated prolactin levels can cause visual field impairment
- Hyperprolactinemia can be associated with amenorrhea, galactorrhea, and infertility
- A complete evaluation of the pituitary is indicated before treatment with bromocriptine mesylate 2
- Patients with hyperprolactinemia should be monitored closely for signs and symptoms of tumor expansion 2
From the Research
Significance of Elevated Prolactin Levels
Elevated prolactin levels in a 28-year-old female can have several implications, including:
- Hyperprolactinemia, which can disrupt ovarian function and lead to hypogonadism 3
- Potential presence of a prolactin-producing pituitary tumor, which can be treated with bromocriptine or hypophysectomy 3
- Marginally elevated prolactin levels may require further evaluation, including magnetic resonance imaging (MRI) and screening for acromegaly 4
- Rarely, elevated prolactin levels can be caused by ovarian cancer, which can produce prolactin and lead to hyperprolactinemia 5
Potential Causes of Hyperprolactinemia
The potential causes of hyperprolactinemia in a 28-year-old female include:
- Prolactinoma, which is the most common cause of severe hyperprolactinemia 6
- Ovarian teratoma, which can contain prolactin-producing tissue and lead to ectopic hyperprolactinemia 7
- Ovarian cancer, which can produce prolactin and lead to hyperprolactinemia 5
- Other potential causes, such as primary hypothyroidism, which should be ruled out with a screening TSH test 4
Diagnostic Evaluation
The diagnostic evaluation of elevated prolactin levels in a 28-year-old female may include: