National consensus on the management of patients with hyperprolactinemia (2016)
Keywords:national consensus, hyperprolactinemia, prolactin, pituitary tumors, dopamine agonists
Hyperprolactinemia is a steady rise prolactin in serum. Hyperprolactinemia can be physiological, pathological and pharmacological. Pathologic causes include the specific state of the anterior hypophyseal lobe, disorders of the hypothalamic-pituitary system and systemic disorders. If there is a diagnosis of hyperprolactinemia it is recommended to exclude its secondary causes: pregnancy, kidney or liver failure, hypothyroidism, parasellar tumors.
For diagnosis a single evaluation prolactin serum levels (≥ 25 ng/ml in females and ≥ 20 ng/ml in males) is enough. Laboratory tests should be evaluated in conjunction with clinical data and additional methods: evaluation of stress, breast ultrasound and/or mammography, assessment of the gonadotropins, estradiol and progesterone levels. In patients with hyperprolactinemia without clinical manifestations it should be macroprolactinemia excluded. There is pharmacological hyperprolactinemia if prolactin level ≈ 200 ng/ml, microprolactinoma if 250 ng/ml, macroprolactinoma if 500 ng/ml and above. Neuroimaging study should be performed in patients with any degree of hyperprolactinemia to exclude hypothalamic-pituitary area pathology.
Treatment goal is normalize the prolactin level, to restore gonadal function and galactorrhea termination and, in the case of prolactinoma to reduce the tumor mass and local compression effects. Treatment often includes administration of dopamine agonists such as bromocriptine or cabergoline, or the use of herbal medicines with dopaminergic action, containing standardized extracts of Vitex agnus castus. Cabergoline is the drug of first line as the most effective against the normalization of prolactin levels and reduce the size of the pituitary tumor.
Surgical treatment (transsphenoidal surgery) is recommended for patients with intolerance to high doses of cabergoline and resistance to other drugs in this group. Radiation therapy
should be used when radical surgery is impossible, in cases of intolerance or resistance to dopamine agonists, while aggressive prolactinoma or carcinomas.
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