From the Guidelines
The next step in the workup of a young female with mildly elevated prolactin levels on two occasions should be to assess baseline macroprolactin levels to determine if the elevation is due to macroprolactinemia, a condition with low biological activity. This approach is based on the recent consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence, which strongly recommends assessing baseline macroprolactin levels in cases of mildly or incidentally elevated serum prolactin 1. The rationale behind this step is that macroprolactin, which consists of dimeric and polymeric forms of prolactin usually associated with an antibody, can circulate and cause elevated prolactin levels without excess monomeric prolactin, which has biological activity. Key points to consider in this workup include:
- Macroprolactinemia is present in 10-40% of individuals with hyperprolactinemia, and its presence can help differentiate between benign and pathological causes of elevated prolactin levels 1.
- Routine assays do not distinguish between monomeric prolactin and macroprolactin, making secondary analysis necessary to detect macroprolactin in the initial investigation of asymptomatic individuals with hyperprolactinemia 1.
- The presence of macroprolactinemia may not necessarily lead to clinical features of prolactin excess, as evidenced by a cohort of patients aged 11-18 years who did not develop such features during an observation period of up to 8 years 1. Given these considerations, assessing baseline macroprolactin levels is a crucial step in the workup of mildly elevated prolactin levels in young females, as it can help guide further management decisions and avoid unnecessary investigations or interventions.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps in Workup
- The next step in the workup of a young female with mildly elevated prolactin levels on two occasions is to rule out other causes of hyperprolactinemia, such as macroprolactinemia, prolactinoma, and other non-tumoral causes 2.
- Imaging procedures, such as magnetic resonance imaging (MRI), may be necessary to determine the presence, size, and extent of any potential lesion 3, 4.
- A careful history and physical examination, as well as routine chemistries, a pregnancy test, and a TSH test, should be performed to exclude other causes of hyperprolactinemia 4, 2.
Treatment Options
- If hyperprolactinemia is confirmed, treatment with dopamine agonists, such as cabergoline or bromocriptine, may be necessary to normalize prolactin levels and restore fertility 4, 5, 6, 2.
- The choice of treatment will depend on the severity of the hyperprolactinemia, the presence of any symptoms, and the patient's desire to become pregnant 2.
Importance of Accurate Diagnosis
- Accurate diagnosis and treatment of hyperprolactinemia are crucial to restore fertility and prevent complications, such as luteal insufficiency and recurrent miscarriage 2.
- Mildly elevated prolactin levels may have a significant impact on fertility, and treatment should be considered in women who wish to become pregnant 2.