What is the clinical significance of elevated prolactin, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels in a 54-year-old woman?

From the Guidelines

I strongly recommend referring this 54-year-old woman to an endocrinologist for further evaluation of her lab findings, as the elevated prolactin level requires investigation to rule out a prolactinoma or other pituitary lesion. These results suggest she is in menopause (elevated FSH and LH) with a mildly elevated prolactin level. While the menopausal hormone pattern is expected for her age, the elevated prolactin requires investigation 1. The endocrinologist will likely order a pituitary MRI to rule out a prolactinoma or other pituitary lesion. They may also repeat the prolactin measurement, as levels can be transiently elevated due to stress, medications (like antipsychotics, some antidepressants, or metoclopramide), or recent breast stimulation.

Some key points to consider in this evaluation include:

• The patient's age and menopausal status, as the median age of menopause in women in the United States is 51 years (range, 41 to 59 years) 1
• The potential effects of estrogen or progestin on chronic diseases, such as osteoporosis, CHD, Alzheimer disease, and colorectal cancer 1
• The importance of assessing fracture risk and using bisphosphonates according to guidelines, particularly in postmenopausal women 1

If a prolactinoma is confirmed, treatment options include dopamine agonists like cabergoline (0.25-1mg twice weekly) or bromocriptine (2.5-15mg daily). For menopausal symptoms, hormone replacement therapy could be considered if she's symptomatic and has no contraindications. Until she sees the specialist, advise her to report any new headaches, visual changes, or unusual discharge from her breasts, as these could indicate a growing pituitary lesion.

From the Research

Clinical Significance of Elevated Hormone Levels

The clinical significance of elevated prolactin, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels in a 54-year-old woman can be understood through the following points:

• Elevated FSH levels are a characteristic of menopause, with levels increasing roughly six years before the final menstrual period and reaching a menopausal plateau that is nearly 14 times the level of FSH observed in men 2.
• FSH measurement is of little value in the assessment of women during the menopausal transition because it cannot be interpreted reliably, and ovulatory cycles may occur subsequent to the observation of postmenopausal FSH levels 3.
• Elevated basal FSH in regularly menstruating women may represent a stage of menopausal transition consequent on premature ovarian failure, with associated higher basal LH and follicular phase LH concentrations, slower follicular growth, and lower luteal phase salivary progesterone 4.
• Hyperprolactinemia is associated with suppression of the hypothalamic-pituitary-gonadal axis and consequent hypogonadism, manifesting loss of libido, infertility, and osteoporosis long-term in both male and female patients, with associated menstrual irregularities, amenorrhea, and galactorrhea in women 5.
• Hormone replacement therapy (HRT) can decrease FSH, LH, and prolactin levels, increase estradiol and estrone levels, and have no modifications in testosterone and androstenedione plasma levels 6.

Hormonal Changes and Menopause

The hormonal changes associated with menopause, including elevated FSH, LH, and prolactin levels, can have various clinical implications, such as:

• Menstrual irregularities and amenorrhea
• Infertility and loss of libido
• Osteoporosis and increased risk of fractures
• Galactorrhea and other symptoms associated with hyperprolactinemia
• Psychiatric morbidities, such as depression and anxiety, which may be related to the increase in FSH levels 2.

Treatment Options

Treatment options for elevated hormone levels in menopausal women may include:

• Hormone replacement therapy (HRT) to decrease FSH, LH, and prolactin levels and increase estradiol and estrone levels 6
• Dopamine agonist therapy to control tumor size and normalize serum prolactin levels in patients with prolactinoma 5
• Gonadal steroid hormone replacement therapy to restore gonadal and sexual function and fertility 5.