Hyperprolactinemia resident survival guide: Difference between revisions

Latest revision as of 20:00, 15 October 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD [2]

Overview

Hyperprolactinemia is defined as high circulating levels of prolactin in the blood. The cut-off values of serum prolactin for hyperprolactinemia are greater than 20 ng/ml in men and postmenopausal women and greater than 30ng/ml in premenopausal women.^[1] Prolactin hormone is produced by lactotroph cells located in the anterior lobe of the pituitary gland. It is responsible for lactation and the development of breasts in females during pregnancy. Elevated levels of prolactin cause galactorrhea, menstrual irregularities, and failure to conceive in females and erectile dysfunction, hypogonadism, and infertility in males. This section provides a short and straight to the point overview of the hyperprolactinemia.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Severe burns on the chest can cause hyperprolactinemia due to neural stimulation similar to suckling. ^[2]

Common Causes

Pregnancy^[3]
Lactation^[3]
Prolactinoma^[4]
Injury to dopaminergic neurons in the hypothalamus (sarcoidosis, craniopharyngioma, and metastatic brain carcinoma)^[4]
Section of the hypothalamic-pituitary stalk
Antipsychotics (risperidone, haloperidol, and phenothiazine)^[5]
Selective serotonin reuptake inhibitors
Metoclopramide^[6]
Domperidone^[7]
Methyldopa^[8]
Verapamil
Familial hyperprolactinemia^[9]
Hypothyroidism^[10]
Chronic renal failure
Macroprolactinoma
Exercise

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hyperprolactinemia according to an Endocrine Society Clinical Practice guidelines:^[1]^[11]

Characterize the symptoms

Inquire about any present illness like hypothyroidism, chronic renal failure, and the use of medications known to cause hyperprolactinemia.

Measure serum prolactin. Elevated serum prolactin

Mesure serum TSH. TSH levels elevated?

Yes

No

Treat hypothyroidism

Perform the MRI with the contrast of the brain. Does it show any mass in the hypothalamic-pituitary region?

Levels of TSH and prolactin should be reassessed after 6-12 weeks.

Yes

No

The levels of other pituitary hormones should be evaluated: Plasma corticotropins (ACTH), Serum TSH, Insulin-like growth factors, Follicle-stimulating hormone, Luteinizing hormone, Estradiol/ Testosterone

Treatment

Shown below is an algorithm summarizing the treatment of hyperprolactinemia:^[1]^[12]^[13]^[14]

The prolactinoma are treated in the following patients:

A macroadenoma causing neurological symptoms such as headache and visual impairment due to compression of the optic chiasm.
Hypogonadism and galactorrhea due to increased prolactin secretion.
Infertility in women with disrupted luteal phase.

The drug of choice for prolactinoma are:

Dopamine agonists as they decrease prolactin secretion and reduce the size of the prolactinoma.
Cabergoline is the preferred drug because of its efficacy and lower incidence of nausea and side effects compared to bromocriptine.

Transsphenoidal surgery is done in:

Patients with unsuccessful treatment with dopamine agonists.

A female patient with a known history of lactotroph macroadenoma who wishes to conceive.

The preferred initial dose of cabergoline for microadenoma is 0.25mg twice a week or 0.5mg once a week.
The medicine should be given at dinner or bedtime to reduce the incidence of nausea and drowsiness.

Transsphenoidal surgery has a high success rate in reducing serum prolactin to a normal level.

Do's

While assessing serum prolactin levels "hook effect” should be considered. Patients with macroadenoma can have artifactually low values of serum prolactin between 20 to 200 mcg/L in patients with high levels of serum prolactin i.e. 5000 mcg/L.^[15] This artifact is avoided by repeating the assay by dilution of serum.
Cabergoline is preferred by women who wish to conceive as it is safe in early pregnancy.^[16] Though bromocriptine is also a safe choice with more evidence of reduced events of congenital defects.^[17]
Physician should monitor patients with hyperprolactinemia with normal serum prolactin levels for regular intervals after discontinuing cabergoline. There is a chance of recurrence of hyperprolactinemia in patients after disconticontinuing cabergoline.^[18]

Don'ts

Physician should prescribe certain medications like risperidone, domperidone, methyldopa, metoclopramide, verapamil, and cimetidine with caution in patients with hyperprolactinemia as it raise serum prolactin levels. These medications can blunt the effects of dopamine agonists.
The patients should be monitored for side effects. Cabergoline treatment in prolactinoma patients for more than three months can result in impulse control disorders. Hypersexuality is common in males and compulsive eating disorders in females.^[19]

References

↑ ^1.0 ^1.1 ^1.2 Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA; et al. (2011). "Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 96 (2): 273–88. doi:10.1210/jc.2010-1692. PMID 21296991.
↑ Morley JE, Dawson M, Hodgkinson H, Kalk WJ (1977). "Galactorrhea and hyperprolactinemia associated with chest wall injury". J Clin Endocrinol Metab. 45 (5): 931–5. doi:10.1210/jcem-45-5-931. PMID 562902.
↑ ^3.0 ^3.1 Tyson JE, Hwang P, Guyda H, Friesen HG (1972). "Studies of prolactin secretion in human pregnancy". Am J Obstet Gynecol. 113 (1): 14–20. doi:10.1016/0002-9378(72)90446-2. PMID 5024994.
↑ ^4.0 ^4.1 Kleinberg DL, Noel GL, Frantz AG (1977). "Galactorrhea: a study of 235 cases, including 48 with pituitary tumors". N Engl J Med. 296 (11): 589–600. doi:10.1056/NEJM197703172961103. PMID 840242.
↑ David SR, Taylor CC, Kinon BJ, Breier A (2000). "The effects of olanzapine, risperidone, and haloperidol on plasma prolactin levels in patients with schizophrenia". Clin Ther. 22 (9): 1085–96. doi:10.1016/S0149-2918(00)80086-7. PMID 11048906.
↑ McCallum RW, Sowers JR, Hershman JM, Sturdevant RA (1976). "Metoclopramide stimulates prolactin secretion in man". J Clin Endocrinol Metab. 42 (6): 1148–52. doi:10.1210/jcem-42-6-1148. PMID 777023.
↑ Sowers JR, Sharp B, McCallum RW (1982). "Effect of domperidone, an extracerebral inhibitor of dopamine receptors, on thyrotropin, prolactin, renin, aldosterone, and 18-hydroxycorticosterone secretion in man". J Clin Endocrinol Metab. 54 (4): 869–71. doi:10.1210/jcem-54-4-869. PMID 7037817.
↑ Steiner J, Cassar J, Mashiter K, Dawes I, Fraser TR, Breckenridge A (1976). "Effects of methyldopa on prolactin and growth hormone". Br Med J. 1 (6019): 1186–8. doi:10.1136/bmj.1.6019.1186. PMC 1639736. PMID 1268617.
↑ Newey PJ, Gorvin CM, Cleland SJ, Willberg CB, Bridge M, Azharuddin M; et al. (2013). "Mutant prolactin receptor and familial hyperprolactinemia". N Engl J Med. 369 (21): 2012–2020. doi:10.1056/NEJMoa1307557. PMC 4209110. PMID 24195502.
↑ Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH (1973). "Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone". J Clin Invest. 52 (9): 2324–9. doi:10.1172/JCI107421. PMC 333037. PMID 4199418.
↑ Majumdar A, Mangal NS (2013). "Hyperprolactinemia". J Hum Reprod Sci. 6 (3): 168–75. doi:10.4103/0974-1208.121400. PMC 3853872. PMID 24347930.
↑ Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD; et al. (2006). "Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas". Clin Endocrinol (Oxf). 65 (2): 265–73. doi:10.1111/j.1365-2265.2006.02562.x. PMID 16886971.
↑ Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF (1994). "A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group". N Engl J Med. 331 (14): 904–9. doi:10.1056/NEJM199410063311403. PMID 7915824.
↑ Randall RV, Laws ER, Abboud CF, Ebersold MJ, Kao PC, Scheithauer BW (1983). "Transsphenoidal microsurgical treatment of prolactin-producing pituitary adenomas. Results in 100 patients". Mayo Clin Proc. 58 (2): 108–21. PMID 6681646.
↑ Petakov MS, Damjanović SS, Nikolić-Durović MM, Dragojlović ZL, Obradović S, Gligorović MS; et al. (1998). "Pituitary adenomas secreting large amounts of prolactin may give false low values in immunoradiometric assays. The hook effect". J Endocrinol Invest. 21 (3): 184–8. doi:10.1007/BF03347299. PMID 9591215.
↑ Robert E, Musatti L, Piscitelli G, Ferrari CI (1996). "Pregnancy outcome after treatment with the ergot derivative, cabergoline". Reprod Toxicol. 10 (4): 333–7. doi:10.1016/0890-6238(96)00063-9. PMID 8829257.
↑ Turkalj I, Braun P, Krupp P (1982). "Surveillance of bromocriptine in pregnancy". JAMA. 247 (11): 1589–91. PMID 7062462.
↑ Colao A, Di Sarno A, Cappabianca P, Di Somma C, Pivonello R, Lombardi G (2003). "Withdrawal of long-term cabergoline therapy for tumoral and nontumoral hyperprolactinemia". N Engl J Med. 349 (21): 2023–33. doi:10.1056/NEJMoa022657. PMID 14627787.
↑ Dogansen SC, Cikrikcili U, Oruk G, Kutbay NO, Tanrikulu S, Hekimsoy Z; et al. (2019). "Dopamine Agonist-Induced Impulse Control Disorders in Patients With Prolactinoma: A Cross-Sectional Multicenter Study". J Clin Endocrinol Metab. 104 (7): 2527–2534. doi:10.1210/jc.2018-02202. PMID 30848825.

Template:WikiDoc Sources

[pmid21296991-1] 1.0 ^1.1 ^1.2 Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA; et al. (2011). "Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 96 (2): 273–88. doi:10.1210/jc.2010-1692. PMID 21296991.

[pmid562902-2] Morley JE, Dawson M, Hodgkinson H, Kalk WJ (1977). "Galactorrhea and hyperprolactinemia associated with chest wall injury". J Clin Endocrinol Metab. 45 (5): 931–5. doi:10.1210/jcem-45-5-931. PMID 562902.

[pmid5024994-3] 3.0 ^3.1 Tyson JE, Hwang P, Guyda H, Friesen HG (1972). "Studies of prolactin secretion in human pregnancy". Am J Obstet Gynecol. 113 (1): 14–20. doi:10.1016/0002-9378(72)90446-2. PMID 5024994.

[pmid840242-4] 4.0 ^4.1 Kleinberg DL, Noel GL, Frantz AG (1977). "Galactorrhea: a study of 235 cases, including 48 with pituitary tumors". N Engl J Med. 296 (11): 589–600. doi:10.1056/NEJM197703172961103. PMID 840242.

[pmid11048906-5] David SR, Taylor CC, Kinon BJ, Breier A (2000). "The effects of olanzapine, risperidone, and haloperidol on plasma prolactin levels in patients with schizophrenia". Clin Ther. 22 (9): 1085–96. doi:10.1016/S0149-2918(00)80086-7. PMID 11048906.

[pmid777023-6] McCallum RW, Sowers JR, Hershman JM, Sturdevant RA (1976). "Metoclopramide stimulates prolactin secretion in man". J Clin Endocrinol Metab. 42 (6): 1148–52. doi:10.1210/jcem-42-6-1148. PMID 777023.

[pmid7037817-7] Sowers JR, Sharp B, McCallum RW (1982). "Effect of domperidone, an extracerebral inhibitor of dopamine receptors, on thyrotropin, prolactin, renin, aldosterone, and 18-hydroxycorticosterone secretion in man". J Clin Endocrinol Metab. 54 (4): 869–71. doi:10.1210/jcem-54-4-869. PMID 7037817.

[pmid1268617-8] Steiner J, Cassar J, Mashiter K, Dawes I, Fraser TR, Breckenridge A (1976). "Effects of methyldopa on prolactin and growth hormone". Br Med J. 1 (6019): 1186–8. doi:10.1136/bmj.1.6019.1186. PMC 1639736. PMID 1268617.

[pmid24195502-9] Newey PJ, Gorvin CM, Cleland SJ, Willberg CB, Bridge M, Azharuddin M; et al. (2013). "Mutant prolactin receptor and familial hyperprolactinemia". N Engl J Med. 369 (21): 2012–2020. doi:10.1056/NEJMoa1307557. PMC 4209110. PMID 24195502.

[pmid4199418-10] Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH (1973). "Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone". J Clin Invest. 52 (9): 2324–9. doi:10.1172/JCI107421. PMC 333037. PMID 4199418.

[pmid24347930-11] Majumdar A, Mangal NS (2013). "Hyperprolactinemia". J Hum Reprod Sci. 6 (3): 168–75. doi:10.4103/0974-1208.121400. PMC 3853872. PMID 24347930.

[pmid16886971-12] Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD; et al. (2006). "Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas". Clin Endocrinol (Oxf). 65 (2): 265–73. doi:10.1111/j.1365-2265.2006.02562.x. PMID 16886971.

[pmid7915824-13] Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF (1994). "A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group". N Engl J Med. 331 (14): 904–9. doi:10.1056/NEJM199410063311403. PMID 7915824.

[pmid6681646-14] Randall RV, Laws ER, Abboud CF, Ebersold MJ, Kao PC, Scheithauer BW (1983). "Transsphenoidal microsurgical treatment of prolactin-producing pituitary adenomas. Results in 100 patients". Mayo Clin Proc. 58 (2): 108–21. PMID 6681646.

[pmid9591215-15] Petakov MS, Damjanović SS, Nikolić-Durović MM, Dragojlović ZL, Obradović S, Gligorović MS; et al. (1998). "Pituitary adenomas secreting large amounts of prolactin may give false low values in immunoradiometric assays. The hook effect". J Endocrinol Invest. 21 (3): 184–8. doi:10.1007/BF03347299. PMID 9591215.

[pmid8829257-16] Robert E, Musatti L, Piscitelli G, Ferrari CI (1996). "Pregnancy outcome after treatment with the ergot derivative, cabergoline". Reprod Toxicol. 10 (4): 333–7. doi:10.1016/0890-6238(96)00063-9. PMID 8829257.

[pmid7062462-17] Turkalj I, Braun P, Krupp P (1982). "Surveillance of bromocriptine in pregnancy". JAMA. 247 (11): 1589–91. PMID 7062462.

[pmid14627787-18] Colao A, Di Sarno A, Cappabianca P, Di Somma C, Pivonello R, Lombardi G (2003). "Withdrawal of long-term cabergoline therapy for tumoral and nontumoral hyperprolactinemia". N Engl J Med. 349 (21): 2023–33. doi:10.1056/NEJMoa022657. PMID 14627787.

[pmid30848825-19] Dogansen SC, Cikrikcili U, Oruk G, Kutbay NO, Tanrikulu S, Hekimsoy Z; et al. (2019). "Dopamine Agonist-Induced Impulse Control Disorders in Patients With Prolactinoma: A Cross-Sectional Multicenter Study". J Clin Endocrinol Metab. 104 (7): 2527–2534. doi:10.1210/jc.2018-02202. PMID 30848825.

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@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Resident survival guide project}}
+{{WikiDoc CMG}}; {{AE}} {{MSJ}}
-{{WikiDoc CMG}}; {{AE}}
 ==Overview==
-This section provides a short and straight to the point overview of the disease or symptom.  The first sentence of the overview must contain the name of the disease.
+[[Hyperprolactinemia]] is defined as high circulating levels of [[prolactin]] in the blood. The cut-off values of serum [[prolactin]] for [[hyperprolactinemia]] are greater than 20 ng/ml in men and postmenopausal women and greater than 30ng/ml in premenopausal women.<ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref> [[Prolactin]] [[hormone]] is produced by lactotroph cells located in the anterior lobe of the [[pituitary gland]]. It is responsible for [[lactation]] and the development of [[breasts]] in females during [[pregnancy]]. Elevated levels of [[prolactin]] cause [[galactorrhea]], menstrual irregularities, and failure to conceive in females and [[erectile dysfunction]], [[hypogonadism]], and [[infertility]] in males. This section provides a short and straight to the point overview of the [[hyperprolactinemia]].
 ==Causes==
 ===Life Threatening Causes===
 Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
-* Severe burns on the chest can cause hyperprolactinemia due to neural stimulation similar to suckling. <ref name="pmid562902">{{cite journal| author=Morley JE, Dawson M, Hodgkinson H, Kalk WJ| title=Galactorrhea and hyperprolactinemia associated with chest wall injury. | journal=J Clin Endocrinol Metab | year= 1977 | volume= 45 | issue= 5 | pages= 931-5 | pmid=562902 | doi=10.1210/jcem-45-5-931 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=562902  }} </ref>
+* Severe [[burn|burns]] on the chest can cause [[hyperprolactinemia]] due to neural stimulation similar to [[Breastfeeding|suckling]]. <ref name="pmid562902">{{cite journal| author=Morley JE, Dawson M, Hodgkinson H, Kalk WJ| title=Galactorrhea and hyperprolactinemia associated with chest wall injury. | journal=J Clin Endocrinol Metab | year= 1977 | volume= 45 | issue= 5 | pages= 931-5 | pmid=562902 | doi=10.1210/jcem-45-5-931 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=562902  }} </ref>
 ===Common Causes===
-* Pregnancy
+* [[Pregnancy]]<ref name="pmid5024994">{{cite journal| author=Tyson JE, Hwang P, Guyda H, Friesen HG| title=Studies of prolactin secretion in human pregnancy. | journal=Am J Obstet Gynecol | year= 1972 | volume= 113 | issue= 1 | pages= 14-20 | pmid=5024994 | doi=10.1016/0002-9378(72)90446-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5024994  }} </ref>
-* Lactation
+* [[Lactation]]<ref name="pmid5024994">{{cite journal| author=Tyson JE, Hwang P, Guyda H, Friesen HG| title=Studies of prolactin secretion in human pregnancy. | journal=Am J Obstet Gynecol | year= 1972 | volume= 113 | issue= 1 | pages= 14-20 | pmid=5024994 | doi=10.1016/0002-9378(72)90446-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5024994  }} </ref>
-* Prolactinoma
+* [[Prolactinoma]]<ref name="pmid840242">{{cite journal| author=Kleinberg DL, Noel GL, Frantz AG| title=Galactorrhea: a study of 235 cases, including 48 with pituitary tumors. | journal=N Engl J Med | year= 1977 | volume= 296 | issue= 11 | pages= 589-600 | pmid=840242 | doi=10.1056/NEJM197703172961103 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=840242  }} </ref>
-* Injury to dopaminergic neurons in the hypothalamus (sarcoidosis, craniopharyngioma, and metastatic brain carcinoma)
+* Injury to dopaminergic neurons in the [[hypothalamus]] ([[sarcoidosis]], [[craniopharyngioma]], and metastatic brain carcinoma)<ref name="pmid840242">{{cite journal| author=Kleinberg DL, Noel GL, Frantz AG| title=Galactorrhea: a study of 235 cases, including 48 with pituitary tumors. | journal=N Engl J Med | year= 1977 | volume= 296 | issue= 11 | pages= 589-600 | pmid=840242 | doi=10.1056/NEJM197703172961103 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=840242  }} </ref>
 * Section of the hypothalamic-pituitary stalk
-* Antipsychotics (risperidone, haloperidol, and phenothiazine)
+* Antipsychotics ([[risperidone]], [[haloperidol]], and [[phenothiazine]])<ref name="pmid11048906">{{cite journal| author=David SR, Taylor CC, Kinon BJ, Breier A| title=The effects of olanzapine, risperidone, and haloperidol on plasma prolactin levels in patients with schizophrenia. | journal=Clin Ther | year= 2000 | volume= 22 | issue= 9 | pages= 1085-96 | pmid=11048906 | doi=10.1016/S0149-2918(00)80086-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11048906  }} </ref>
 * Selective serotonin reuptake inhibitors
-* Metoclopramide
+* [[Metoclopramide]]<ref name="pmid777023">{{cite journal| author=McCallum RW, Sowers JR, Hershman JM, Sturdevant RA| title=Metoclopramide stimulates prolactin secretion in man. | journal=J Clin Endocrinol Metab | year= 1976 | volume= 42 | issue= 6 | pages= 1148-52 | pmid=777023 | doi=10.1210/jcem-42-6-1148 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=777023  }} </ref>
-* Domperidone
+* [[Domperidone]]<ref name="pmid7037817">{{cite journal| author=Sowers JR, Sharp B, McCallum RW| title=Effect of domperidone, an extracerebral inhibitor of dopamine receptors, on thyrotropin, prolactin, renin, aldosterone, and 18-hydroxycorticosterone secretion in man. | journal=J Clin Endocrinol Metab | year= 1982 | volume= 54 | issue= 4 | pages= 869-71 | pmid=7037817 | doi=10.1210/jcem-54-4-869 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7037817  }} </ref>
-* Methyldopa
+* [[Methyldopa]]<ref name="pmid1268617">{{cite journal| author=Steiner J, Cassar J, Mashiter K, Dawes I, Fraser TR, Breckenridge A| title=Effects of methyldopa on prolactin and growth hormone. | journal=Br Med J | year= 1976 | volume= 1 | issue= 6019 | pages= 1186-8 | pmid=1268617 | doi=10.1136/bmj.1.6019.1186 | pmc=1639736 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1268617  }} </ref>
-* Verapamil
+* [[Verapamil]]
-* Familial hyperprolactinemia
+* Familial [[hyperprolactinemia]]<ref name="pmid24195502">{{cite journal| author=Newey PJ, Gorvin CM, Cleland SJ, Willberg CB, Bridge M, Azharuddin M | display-authors=etal| title=Mutant prolactin receptor and familial hyperprolactinemia. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 21 | pages= 2012-2020 | pmid=24195502 | doi=10.1056/NEJMoa1307557 | pmc=4209110 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24195502  }} </ref>
-* Hypothyroidism
+* [[Hypothyroidism]]<ref name="pmid4199418">{{cite journal| author=Snyder PJ, Jacobs LS, Utiger RD, Daughaday WH| title=Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone. | journal=J Clin Invest | year= 1973 | volume= 52 | issue= 9 | pages= 2324-9 | pmid=4199418 | doi=10.1172/JCI107421 | pmc=333037 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4199418  }} </ref>
-* Chronic renal failure
+* [[Chronic renal failure]]
-* macroprolactinomas
+* Macroprolactinoma
-* Exercise
+* [[Physical exercise|Exercise]]
 ==Diagnosis==
-Shown below is an algorithm summarizing the diagnosis of [[hyperprolactinemia]] according to an Endocrine Society Clinical Practice guidelines<ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref>:
+Shown below is an algorithm summarizing the diagnosis of [[hyperprolactinemia]] according to an Endocrine Society Clinical Practice guidelines:<ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref><ref name="pmid24347930">{{cite journal| author=Majumdar A, Mangal NS| title=Hyperprolactinemia. | journal=J Hum Reprod Sci | year= 2013 | volume= 6 | issue= 3 | pages= 168-75 | pmid=24347930 | doi=10.4103/0974-1208.121400 | pmc=3853872 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24347930  }} </ref>
 {{Family tree/start}}
-{{Family tree | | | | A01 | | | |A01= Suggestive symptoms including headache, oligomenorrhea, infertility, hypogonadism, erectile dysfunction, and galactorrhea}}
+{{Family tree | | | | A01 | | | | | A01=<div style="float: center; text-align: left; height: 12em; width: 15em; padding:1em;">  Characterize the symptoms
-{{Family tree | | | | |!| | | | | }}
+*[[Headache]]
-{{Family tree | | | | |!| | | | | }}
+*[[Oligomenorrhea]]
-{{Family tree | | | | |!| | | | | }}
+*[[Infertility]]
-{{Family tree | | | | B01 | | | |B01= Detailed history and physical examination should be performed to rule out hypothyroidism, chronic renal failure, and the use of medications known to cause hyperprolactinemia.}}
+*[[Hypogonadism]]
+*[[Erectile dysfunction]]
+*[[Galactorrhea]] }}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
-{{Family tree | | | | C01 | | | |C01= Serum prolactin measured. The cut-off values of serum prolactin for hyperprolactinemia are greater than 20 ng/ml in men and postmenopausal women and greater than 30ng/ml in premenopausal women.}}
+{{Family tree | | | | B01 | | | |B01= <div style="float: left; text-align: left; height: 8em; width: 15em; padding:1em;"> Inquire about any present illness like [[hypothyroidism]], [[chronic renal failure]], and the use of medications known to cause [[hyperprolactinemia]].}}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
-{{Family tree | | | | D01 | | | |D01= MRI with the contrast of brain should be performed to rule out any mass in the hypothalamic-pituitary region.}}
+{{Family tree | | | | C01 | | | |C01= <div style="float: left; text-align: left;"> Measure serum [[prolactin]]. Elevated serum [[prolactin]] }}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
 {{Family tree | | | | |!| | | | | }}
-{{Family tree | | | | E01 | | | |E01= The levels of other pituitary hormones should be evaluated. The following hormone levels should be evaluated: Plasma corticotropins (ACTH), Serum TSH, Insulin-like growth factors, Follicle-stimulating hormone, Luteinizing hormone, Estradiol/ Testosterone}}
+{{Family tree | | | | D01 | | | |D01= <div style="float: left; text-align: left;"> Mesure serum [[Thyroid-stimulating hormone|TSH]]. [[Thyroid-stimulating hormone|TSH]] levels elevated?}}
+{{familytree | | |,|-|^|-|.| }}
+{{familytree | | E01 | | |E02|E01= Yes | E02= No}}
+{{familytree | | |!| | | |!| }}
+{{familytree | | F01 | | |F02|F01= <div style="float: left; text-align: left;">Treat [[hypothyroidism]] | F02= <div style="float: left; text-align: left;">Perform the [[Magnetic resonance imaging|MRI]] with the contrast of the [[brain]]. Does it show any mass in the hypothalamic-pituitary region? }}
+{{familytree | | |!| | |,|-|^|-|.| }}
+{{familytree | | G01 | |G02 | | G03 |G01= <div style="float: left; text-align: left;"> Levels of TSH and [[prolactin]] should be reassessed after 6-12 weeks. | G02= Yes | G03= No}}
+{{familytree | | | | | |!| | | | | }}
+{{familytree | | | | | |H01| | | |H01= <div style="float: left; text-align: left;"> The levels of other pituitary hormones should be evaluated: Plasma [[Adrenocorticotropic hormone|corticotropins]] (ACTH), Serum TSH, Insulin-like growth factors, [[Follicle-stimulating hormone]], [[Luteinizing hormone]], Estradiol/ [[Testosterone (transdermal)|Testosterone]] }}
 {{Family tree/end}}
-{{familytree/end}}
 ==Treatment==
+Shown below is an algorithm summarizing the treatment of [[hyperprolactinemia]]:<ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref><ref name="pmid16886971">{{cite journal| author=Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD | display-authors=etal| title=Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. | journal=Clin Endocrinol (Oxf) | year= 2006 | volume= 65 | issue= 2 | pages= 265-73 | pmid=16886971 | doi=10.1111/j.1365-2265.2006.02562.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16886971  }} </ref><ref name="pmid7915824">{{cite journal| author=Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF| title=A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group. | journal=N Engl J Med | year= 1994 | volume= 331 | issue= 14 | pages= 904-9 | pmid=7915824 | doi=10.1056/NEJM199410063311403 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7915824  }} </ref><ref name="pmid6681646">{{cite journal| author=Randall RV, Laws ER, Abboud CF, Ebersold MJ, Kao PC, Scheithauer BW| title=Transsphenoidal microsurgical treatment of prolactin-producing pituitary adenomas. Results in 100 patients. | journal=Mayo Clin Proc | year= 1983 | volume= 58 | issue= 2 | pages= 108-21 | pmid=6681646 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6681646  }} </ref>
 {{Family tree/start}}
-{{Family tree | | | | A01 | | | |A01= The prolactinoma are treated in the following patients<ref name="pmid16886971">{{cite journal| author=Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD | display-authors=etal| title=Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. | journal=Clin Endocrinol (Oxf) | year= 2006 | volume= 65 | issue= 2 | pages= 265-73 | pmid=16886971 | doi=10.1111/j.1365-2265.2006.02562.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16886971  }} </ref><ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref><ref name="pmid32130815">{{cite journal| author=Melmed S| title=Pituitary-Tumor Endocrinopathies. | journal=N Engl J Med | year= 2020 | volume= 382 | issue= 10 | pages= 937-950 | pmid=32130815 | doi=10.1056/NEJMra1810772 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32130815  }} </ref>:
+{{Family tree | | | | A01 | | | |A01=<div style="float: left; text-align: left; height: 16em; width: 19em; padding:1em;">The [[prolactinoma]] are treated in the following patients:
-* A macroadenoma causing neurological symptoms such as headache and visual impairment due to compression of the optic chiasm.
+* A macroadenoma causing neurological symptoms such as [[headache]] and visual impairment due to compression of the [[optic chiasm]].
-* Hypogonadism and galactorrhea due to increased prolactin secretion.
+* [[Hypogonadism]] and [[galactorrhea]] due to increased [[prolactin]] secretion.
-* Infertility in women with disrupted luteal phase.
+* [[Infertility]] in women with disrupted luteal phase.
 }}
 {{Family tree | |,|-|-|^|-|-|.| | }}
-{{Family tree | B01 | | | | B02 |B01= The drug of choice for prolactinoma are dopamine agonists as they decrease prolactin secretion and reduce the size of the prolactinoma.<ref name="pmid6229205">{{cite journal| author=Vance ML, Evans WS, Thorner MO| title=Drugs five years later. Bromocriptine. | journal=Ann Intern Med | year= 1984 | volume= 100 | issue= 1 | pages= 78-91 | pmid=6229205 | doi=10.7326/0003-4819-100-1-78 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6229205  }} </ref><ref name="pmid22828169">{{cite journal| author=Wang AT, Mullan RJ, Lane MA, Hazem A, Prasad C, Gathaiya NW | display-authors=etal| title=Treatment of hyperprolactinemia: a systematic review and meta-analysis. | journal=Syst Rev | year= 2012 | volume= 1 | issue=  | pages= 33 | pmid=22828169 | doi=10.1186/2046-4053-1-33 | pmc=3483691 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22828169  }} </ref> Cabergoline is the preferred drug because of its efficacy and lower incidence of nausea and side effects compared to bromocriptine.<ref name="pmid7915824">{{cite journal| author=Webster J, Piscitelli G, Polli A, Ferrari CI, Ismail I, Scanlon MF| title=A comparison of cabergoline and bromocriptine in the treatment of hyperprolactinemic amenorrhea. Cabergoline Comparative Study Group. | journal=N Engl J Med | year= 1994 | volume= 331 | issue= 14 | pages= 904-9 | pmid=7915824 | doi=10.1056/NEJM199410063311403 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7915824  }} </ref><ref name="pmid8964874">{{cite journal| author=Biller BM, Molitch ME, Vance ML, Cannistraro KB, Davis KR, Simons JA | display-authors=etal| title=Treatment of prolactin-secreting macroadenomas with the once-weekly dopamine agonist cabergoline. | journal=J Clin Endocrinol Metab | year= 1996 | volume= 81 | issue= 6 | pages= 2338-43 | pmid=8964874 | doi=10.1210/jcem.81.6.8964874 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8964874  }} </ref> | B02= Transsphenoidal surgery is done in:
+{{Family tree | B01 | | | | B02 |B01=<div style="float: left; text-align: left; height: 13em; width: 19em; padding:1em;">The drug of choice for [[prolactinoma]] are:
-* Patients with unsuccessful treatment with dopamine agonists.
+* [[Dopamine agonist|Dopamine agonists]] as they decrease [[prolactin]] secretion and reduce the size of the [[prolactinoma]].
-* A female patient with a known history of lactotroph macroadenoma who wishes to conceive.
+* [[Cabergoline]] is the preferred drug because of its efficacy and lower incidence of [[Nausea and vomiting|nausea]] and side effects compared to [[bromocriptine]]. |B02= <div style="float: left; text-align: left; height: 13em;"> Transsphenoidal surgery is done in:
-* Transsphenoidal surgery has a high success rate in reducing serum prolactin to a normal level.<ref name="pmid8626821">{{cite journal| author=Feigenbaum SL, Downey DE, Wilson CB, Jaffe RB| title=Transsphenoidal pituitary resection for preoperative diagnosis of prolactin-secreting pituitary adenoma in women: long term follow-up. | journal=J Clin Endocrinol Metab | year= 1996 | volume= 81 | issue= 5 | pages= 1711-9 | pmid=8626821 | doi=10.1210/jcem.81.5.8626821 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8626821  }} </ref> <ref name="pmid6681646">{{cite journal| author=Randall RV, Laws ER, Abboud CF, Ebersold MJ, Kao PC, Scheithauer BW| title=Transsphenoidal microsurgical treatment of prolactin-producing pituitary adenomas. Results in 100 patients. | journal=Mayo Clin Proc | year= 1983 | volume= 58 | issue= 2 | pages= 108-21 | pmid=6681646 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6681646  }} </ref> }}
+* Patients with unsuccessful treatment with [[Dopamine agonist|dopamine agonists]].
-{{familytree | |!| | | | | | | | | | | | | | }}
+* A female patient with a known history of lactotroph macroadenoma who wishes to conceive. }}
-{{Family tree | C01 | | | | |C01= The preferred initial dose of cabergoline for microadenoma is 0.25mg twice a week or 0.5mg once a week. The medicine should be given at dinner or bedtime to reduce the incidence of nausea and drowsiness.<ref name="pmid21296991">{{cite journal| author=Melmed S, Casanueva FF, Hoffman AR, Kleinberg DL, Montori VM, Schlechte JA | display-authors=etal| title=Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. | journal=J Clin Endocrinol Metab | year= 2011 | volume= 96 | issue= 2 | pages= 273-88 | pmid=21296991 | doi=10.1210/jc.2010-1692 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21296991  }} </ref> }}
+{{Family tree | |!| | | | | |!| | }}
-{{familytree | |!| | | | | | | | | | | | | | }}
+{{Family tree | C01 | | | | C02 |C01=<div style="float: left; text-align: left; height: 14em; width: 16em; padding:1em;">
-{{Family tree | D01 | | | | |D01= Cabergoline is also preferred by women who wish to conceive as it is safe in early pregnancy.<ref name="pmid12401507">{{cite journal| author=Ricci E, Parazzini F, Motta T, Ferrari CI, Colao A, Clavenna A | display-authors=etal| title=Pregnancy outcome after cabergoline treatment in early weeks of gestation. | journal=Reprod Toxicol | year= 2002 | volume= 16 | issue= 6 | pages= 791-3 | pmid=12401507 | doi=10.1016/s0890-6238(02)00055-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12401507  }} </ref> Though bromocriptine is also a safe choice with more evidence of reduced events of congenital defects.<ref name="pmid25996397">{{cite journal| author=| title=Reorganized text. | journal=JAMA Otolaryngol Head Neck Surg | year= 2015 | volume= 141 | issue= 5 | pages= 428 | pmid=25996397 | doi=10.1001/jamaoto.2015.0540 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25996397  }} </ref> }}
+*The preferred initial dose of [[cabergoline]] for microadenoma is 0.25mg twice a week or 0.5mg once a week.
+*The medicine should be given at dinner or bedtime to reduce the incidence of [[Nausea and vomiting|nausea]] and [[Somnolence|drowsiness]]. |C02= Transsphenoidal surgery has a high success rate in reducing serum [[prolactin]] to a normal level. }}
 {{Family tree/end}}
 ==Do's==
-* The content in this section is in bullet points.
+* While assessing [[serum]] [[prolactin]] levels "hook effect” should be considered. Patients with macroadenoma can have artifactually low values of serum [[prolactin]] between 20 to 200 mcg/L in patients with high levels of serum [[prolactin]] i.e. 5000 mcg/L.<ref name="pmid9591215">{{cite journal| author=Petakov MS, Damjanović SS, Nikolić-Durović MM, Dragojlović ZL, Obradović S, Gligorović MS | display-authors=etal| title=Pituitary adenomas secreting large amounts of prolactin may give false low values in immunoradiometric assays. The hook effect. | journal=J Endocrinol Invest | year= 1998 | volume= 21 | issue= 3 | pages= 184-8 | pmid=9591215 | doi=10.1007/BF03347299 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9591215  }} </ref> This artifact is avoided by repeating the assay by dilution of serum.
+* Cabergoline is preferred by women who wish to conceive as it is safe in early pregnancy.<ref name="pmid8829257">{{cite journal| author=Robert E, Musatti L, Piscitelli G, Ferrari CI| title=Pregnancy outcome after treatment with the ergot derivative, cabergoline. | journal=Reprod Toxicol | year= 1996 | volume= 10 | issue= 4 | pages= 333-7 | pmid=8829257 | doi=10.1016/0890-6238(96)00063-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8829257  }} </ref> Though bromocriptine is also a safe choice with more evidence of reduced events of congenital defects.<ref name="pmid7062462">{{cite journal| author=Turkalj I, Braun P, Krupp P| title=Surveillance of bromocriptine in pregnancy. | journal=JAMA | year= 1982 | volume= 247 | issue= 11 | pages= 1589-91 | pmid=7062462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7062462  }} </ref>
+* [[Physician]] should monitor patients with [[hyperprolactinemia]] with normal serum [[prolactin]] levels for regular intervals after discontinuing [[cabergoline]]. There is a chance of recurrence of [[hyperprolactinemia]] in patients after disconticontinuing [[cabergoline]].<ref name="pmid14627787">{{cite journal| author=Colao A, Di Sarno A, Cappabianca P, Di Somma C, Pivonello R, Lombardi G| title=Withdrawal of long-term cabergoline therapy for tumoral and nontumoral hyperprolactinemia. | journal=N Engl J Med | year= 2003 | volume= 349 | issue= 21 | pages= 2023-33 | pmid=14627787 | doi=10.1056/NEJMoa022657 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14627787  }} </ref>
 ==Don'ts==
-* Certain medications like risperidone, domperidone, methyldopa, metoclopramide, verapamil, and cimetidine raise serum prolactin levels. These medications can blunt the effects of dopamine agonists.
+* [[Physician]] should prescribe certain medications like [[risperidone]], [[domperidone]], [[methyldopa]], [[metoclopramide]], [[verapamil]], and [[cimetidine]] with caution in patients with [[hyperprolactinemia]] as it raise serum [[prolactin]] levels. These medications can blunt the effects of [[dopamine]] agonists.
-* The patients should be monitored for side effects. Cabergoline treatment in prolactinoma patients for more than three months can result in impulse control disorders. Hypersexuality is common in males and compulsive eating disorders in females.<ref name="pmid30848825">{{cite journal| author=Dogansen SC, Cikrikcili U, Oruk G, Kutbay NO, Tanrikulu S, Hekimsoy Z | display-authors=etal| title=Dopamine Agonist-Induced Impulse Control Disorders in Patients With Prolactinoma: A Cross-Sectional Multicenter Study. | journal=J Clin Endocrinol Metab | year= 2019 | volume= 104 | issue= 7 | pages= 2527-2534 | pmid=30848825 | doi=10.1210/jc.2018-02202 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30848825  }} </ref>
+* The patients should be monitored for side effects. [[Cabergoline]] treatment in [[prolactinoma]] patients for more than three months can result in impulse control disorders. [[Hypersexuality]] is common in males and compulsive eating disorders in females.<ref name="pmid30848825">{{cite journal| author=Dogansen SC, Cikrikcili U, Oruk G, Kutbay NO, Tanrikulu S, Hekimsoy Z | display-authors=etal| title=Dopamine Agonist-Induced Impulse Control Disorders in Patients With Prolactinoma: A Cross-Sectional Multicenter Study. | journal=J Clin Endocrinol Metab | year= 2019 | volume= 104 | issue= 7 | pages= 2527-2534 | pmid=30848825 | doi=10.1210/jc.2018-02202 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30848825  }} </ref>
 ==References==
 {{Reflist|2}}