1. Morning Report
Heather Shenk
5/28/14

2. Hyperprolactinemia
 Prolactin - secreted by the pituitary lactotroph cells
under tonic inhibition by dopamine.
 Physiologic causes of hyperprolactinemia include:
pregnancy, nipple stimulation, exercise, and food
intake.
 If modest hyperprolactinemia, exclude pregnancy
first and repeat test in a fasting state, with no
strenuous exercise before testing.
 If no clear secondary or drug-induced cause should
be assessed by an imaging study (preferably, MRI of
the pituitary gland) to exclude a mass lesion.

3. Cause Result
Pituitary disease Prolactinomas
Growth hormone–secreting tumors (cosecretion of prolactin or pituitary
stalk effects)
Nonfunctioning pituitary tumors (pituitary stalk effects)
Lymphocytic hypophysitis (pituitary stalk effects)
Empty sella syndrome (pituitary stalk effects)
Cushing disease (cosecretion of prolactin or pituitary stalk effects)
Nonpituitary sellar
and parasellar
lesions
Craniopharyngioma
Hypothalamic disease (sarcoidosis, Langerhans cell histiocytosis,
lymphoma)
Metastatic tumors to pituitary/hypothalamus
Meningiomas
Dysgerminomas
Irradiation
Neurogenic Chest wall or spinal cord disease
Breast stimulation/lesions
Drugs Psychotropic agents (butyrophenones and phenothiazines, monoamine
oxidase inhibitors, TCA, fluoxetine, molindone, risperidone, cocaine)
Antihypertensive agents (verapamil, methyldopa, reserpine)
Metoclopramide
(Estrogen in conventionally used doses does not cause
hyperprolactinemia.)
Other Pregnancy, Physiologic cause (coitus, nipple stimulation, strenuous
exercise, stress), Hypothyroidism, Chronic kidney failure, Cirrhosis,
Macroprolactinoma
Idiopathic
Adrenal insufficiency

5. Presentation
 Symptoms: galactorrhea, oligomenorrhea,
amenorrhea, hirsuitism, erectile dysfunction,
decrease libido, infertility, headache, osteopenia.
Mass effect causing peripheral visual field loss.
 Indications for treatment: Estrogen deficiency (pre-
menopausal with amenorrhea and oligomenorrhea),
infertility, bothersome galactorrhea and hirsuitism. In
men, symptomatic testosterone deficiency, reduced
libido or gynecomastia. Headaches, mass effect,
osteopenia, osteoporosis.

6. Treatment
 Exclude secondary causes
 Dopamine agonist – cabergoline, bromocriptine
 Decrease serum prolactin and shrink prolactinoma.
 Use as first line therapy
 Consider withdrawal if normal prolactin level for 2 years
and no visible tumor on MRI
 In women who do not desire pregnancy, estrogen
deficiency may be treated with OCP
 Surgerical resection if unresponsive or poorly
tolerant of medical therapy.
 80% remission for micropolactinoma and 40% for
macroprolactinomas

7. Pregnancy
 Dopamine agonists have no increased risk of fetal
malformations.
 Stop drug after conception – except if history of optic
chiasm compression.
 Prolactinomas may increase in size in pregnancy
and closer monitor is needed – but not by checking
prolactin level.

8. Questions
 26-year-old woman is evaluated for hyperprolactinemia after recent
follow-up laboratory studies showed a serum prolactin level of 55
ng/mL (55 µg/L). Mild hyperprolactinemia (serum prolactin level of 35
ng/mL [35 µg/L]) was detected 6 years ago during an evaluation for
irregular menstrual cycles; an MRI performed at that time showed a
pituitary microadenoma. She was treated with a dopamine agonist,
and subsequent serum prolactin measurements have shown normal
levels until the most recent measurement. The patient underwent
menarche at age 13 years and has had irregular menstrual cycles
since that time, with multiple missed cycles. She has never been
pregnant. Her family history is unremarkable, and she takes no
medication.
 On physical examination, blood pressure is 108/70 mm Hg, pulse
rate is 82/min, and respiration rate is 12/min; BMI is 25. The patient
has a normal distribution of body weight. Breast development is
normal, but breast tenderness is noted on examination. No
galactorrhea, acne, hirsutism, or striae are present.
 Laboratory studies confirm a serum prolactin level of 55 ng/mL (55
µg/L) and show a thyroid-stimulating hormone level of 1.2 µU/mL (1.2
mU/L).

9. Answers
 A. Pregnancy test
 B. Random serum growth hormone measurement
 C. Serum cortisol measurement
 D. Visual field testing

10. Answers
 A. Pregnancy test
 B. Random serum growth hormone measurement
 C. Serum cortisol measurement
 D. Visual field testing
 Key Point
 In a woman with a modestly elevated serum
prolactin level, pregnancy must first be excluded as
a cause before a diagnosis of hyperprolactinemia is
made

11. Question
 33-year-old woman is evaluated for a 5-month history of
amenorrhea and a 3-month history of galactorrhea. The
patient says her menstrual cycles were normal before
onset of amenorrhea. She takes no medication.
 On physical examination, vital signs are normal. Visual
field findings are normal. Bilateral galactorrhea is noted.
 Results of laboratory studies show a serum luteinizing
hormone level of 2 mU/mL (2 units/L), a prolactin level of
965 ng/mL (965 µg/L), and a free thyroxine level of 1.1
ng/dL (14 pmol/L). A serum β-human chorionic
gonadotropin measurement is normal.
 An MRI shows a 1.5-cm sellar mass with suprasellar
extension that impinges on the optic chiasm

12. Answers
 Which of the following is the most appropriate initial
treatment?
 A. Dopamine agonist therapy
 B. Oral contraceptive
 C. Radiation therapy
 D. Transsphenoidal surgical resection

13. Answers
 Which of the following is the most appropriate initial
treatment?
 A. Dopamine agonist therapy
 B. Oral contraceptive
 C. Radiation therapy
 D. Transsphenoidal surgical resection
 Key Point
 In a patient with a macroprolactinoma, administration of a
dopamine agonist, such as cabergoline, is indicated as the
initial treatment.
 Dopamine agonists normalize prolactin levels, correct
amenorrhea and galactorrhea, and decrease tumor size by
more than 50% in 80% to 90% of patients. They are used as
first-line therapy, unless visual field loss is significant and
progressive. Even with mild visual loss, dopamine agonists are