Pituitary

Hyperprolactinemia

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Hyperprolactinemia

  • Symptoms
  1. Galactorrhea
    1. Occurs in 90% of women with Hyperprolactinemia
  2. Amenorrhea
  3. Infertility
  • Diagnosis
  1. Galactorrhea with Amenorrhea is pathognomonic for Hyperprolactinemia
  2. Galactorrhea without Amenorrhea is associated with normal Serum Prolactin
  • Imaging
  • Brain
  1. MRI Brain with IV contrast
    1. Thin cuts through the sella turcica, Hypothalamus and Optic Chiasm
  2. CT Head with cone down sella turcica
    1. Lower Test Sensitivity than MRI for Pituitary Adenoma and associated abnormalities
  • Approach
  • Initial Evaluation
  1. Confirm Hyperprolactinemia
    1. Repeat Serum Prolactin
    2. Repeat in 6 months if repeat Prolactin normal
  2. Evaluate for Physiologic Cause
    1. History
      1. Breast stimulation or Lactation
      2. Sexual Intercourse temporally related to lab test
      3. Excessive Eating, Exercise, Sleep or Stress
    2. Labs
      1. Thyroid Stimulating Hormone (Hypothyroidism)
      2. Urine Pregnancy Test
      3. Serum Creatinine
      4. Consider reproductive hormone levels if Hypogonadism is present
        1. Serum Estrogen
        2. Serum Testosterone
        3. Follicle Stimulating Hormone
        4. Luteinizing hormone
  1. Identify medication related Hyperprolactinemia cause
    1. Discontinue Medication Causes of Hyperprolactinemia
    2. Repeat Prolactin in 1-2 months
  2. No obvious medication cause
    1. Recheck Serum Prolactin in 3 months
    2. Consider lab testing as above (e.g. TSH, HCG)
  1. Identify medication related Hyperprolactinemia cause
    1. Discontinue offending medication
    2. Repeat Prolactin in 1-2 months
  2. No obvious medication cause
    1. Obtain CT or MRI Head (cone-down sella turcica)
    2. Imaging Abnormal
      1. Evaluate Pituitary Tumor (see Prolactinoma)
    3. Imaging Normal
      1. Consider Dopamine Agonist (e.g. Bromocriptine, Cabergoline)
        1. Symptomatic Hyperprolactinemia (e.g. bothersome Galactorrhea or Amenorrhea)
      2. Consider hormonal therapy (Estrogen or testosterone)
        1. Hypogonadism
      3. Repeat evaluation and testing
        1. Repeat Prolactin at 6 month intervals
        2. Repeat CT or MRI Head (cone-down sella) in 1 year
  1. Causes
    1. Empty sella syndrome
    2. Pituitary Adenoma (especially if >200 ng/ml)
    3. Consider medication related Hyperprolactinemia
      1. Less likely to raise the Serum Prolactin this high
  2. Obtain CT or MRI Head (cone-down sella turcica)
    1. Imaging Abnormal
      1. Evaluate Pituitary Tumor (see Prolactinoma)
    2. Imaging Normal
      1. Treatment with Dopamine Agonist (e.g. Bromocriptine, Cabergoline)
      2. Repeat Serum Prolactin every 3 months
      3. Repeat CT or MRI Head (cone-down sella) in 1 year
  • Complications
  1. Osteoporosis (secondary to Hypogonadism)
    1. Consider Bone density scan (DEXA)