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

Treatment of Hyperprolactinemia

The first-line treatment for hyperprolactinemia caused by prolactinomas is dopamine agonist therapy, with cabergoline being the preferred agent due to its superior efficacy and tolerability compared to other options. 1, 2

Diagnostic Evaluation Before Treatment

Before initiating treatment, it's essential to:

• Confirm hyperprolactinemia with a single blood sample collected at any time of day 3
• Consider serial measurements for modestly elevated levels to exclude stress-related elevation 3
• Exclude confounding conditions such as:
  • Hypothyroidism 3, 4
  • Renal or hepatic impairment 3, 4
  • Medication-induced hyperprolactinemia 4, 5
• Measure luteinizing hormone levels to help establish etiology 3
• Consider MRI imaging to evaluate for pituitary tumors if prolactin levels are significantly elevated 3, 6

Treatment Algorithm

First-Line Treatment: Dopamine Agonists

1. Cabergoline:

   • Preferred first-line agent 1, 2
   • More effective at normalizing prolactin levels and reducing tumor size 2
   • Better tolerated than other dopamine agonists 1, 2
   • Typical starting dose is lower than that used for Parkinson's disease 2

2. Bromocriptine:

   • Alternative if cabergoline is not tolerated or contraindicated 7
   • Has more extensive safety data during pregnancy 8
   • May cause more side effects, particularly nausea and orthostatic hypotension 7, 1

Monitoring During Treatment

• Monitor prolactin levels to assess treatment efficacy 3, 1
• For macroprolactinomas:
  • MRI monitoring at 3 months to verify tumor size reduction 1
  • Then after 1 year, yearly for 5 years, and every 5 years if stable 1
• For microprolactinomas:
  • MRI after 1 year and then after 5 years 1
• Echocardiographic monitoring every 6-12 months for patients on cabergoline to assess for cardiac valvulopathy 9

Treatment Duration and Discontinuation

• Once normal prolactin levels are achieved, consider:
  • Gradual dose reduction to the lowest effective dose 1, 2
  • Possible discontinuation after several years of treatment 1, 6
• After discontinuation, continue monitoring prolactin levels as recurrence occurs in 20-30% of cases 1

Special Considerations

Medication-Induced Hyperprolactinemia

• If the causative medication cannot be withdrawn, avoid dopamine agonist therapy 1, 5
• Consider sex steroid replacement to prevent complications like osteoporosis 1

Pregnancy Considerations

• Bromocriptine has more safety data for use in women planning to conceive 8
• Discontinue dopamine agonist therapy immediately once pregnancy is confirmed unless there is risk of significant tumor growth 7, 6

Resistant Cases

• If one dopamine agonist is ineffective, try switching to another 1
• Consider a standardized, individualized, dose-escalating regimen of cabergoline for resistant cases 2
• Surgical resection is an option for patients who do not respond to or cannot tolerate dopamine agonist therapy 6

Important Warnings and Precautions

• Cabergoline has been associated with cardiac valvulopathy at higher doses used for Parkinson's disease 9
• Monitor for fibrotic complications including cardiac valvulopathy, pleural/pericardial effusions, and retroperitoneal fibrosis, especially with long-term use 9, 7
• Bromocriptine can cause symptomatic hypotension, particularly during initial treatment 7
• Patients with unexplained pleuropulmonary disorders should be examined thoroughly and discontinuation of therapy should be considered 7