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====Life-threatening Causes==== | ====Life-threatening Causes==== | ||
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. | ||
* Severe [[Burn|burns]] on the chest can cause [[hyperprolactinemia]] due to neural stimulation similar to suckling | * Severe [[Burn|burns]] on the chest can cause [[hyperprolactinemia]] due to neural stimulation similar to suckling. | ||
====Common Causes==== | ====Common Causes==== | ||
*[[Pregnancy]] | *[[Pregnancy]] | ||
*[[Lactation]] | *[[Lactation]] | ||
*[[Prolactinoma]] | *[[Prolactinoma]] | ||
* 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> | * 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 | * Section of the hypothalamic-pituitary stalk | ||
* Antipsychotics ([[risperidone]], [[haloperidol]], and [[phenothiazine]]) | * Antipsychotics ([[risperidone]], [[haloperidol]], and [[phenothiazine]]) | ||
* Selective serotonin reuptake inhibitors | * Selective serotonin reuptake inhibitors | ||
*[[Metoclopramide]] | *[[Metoclopramide]] | ||
*[[Domperidone]] | *[[Domperidone]] | ||
*[[Methyldopa]] | *[[Methyldopa]] | ||
*[[Verapamil]] | *[[Verapamil]] | ||
* Familial [[hyperprolactinemia]] | * Familial [[hyperprolactinemia]] | ||
*[[Hypothyroidism]] | *[[Hypothyroidism]] | ||
*[[Chronic renal failure]] | *[[Chronic renal failure]] | ||
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===Management=== | ===Management=== | ||
Shown below is an algorithm summarizing the treatment of [[hyperprolactinemia]]: | Shown below is an algorithm summarizing the treatment of [[hyperprolactinemia]]: | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | A01 | | | |A01= The prolactinoma are treated in the following patients: | {{Family tree | | | | A01 | | | |A01= The prolactinoma are treated in the following patients: | ||
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===Do's=== | ===Do's=== | ||
* “Hook effect” should be kept in consideration while assessing serum [[prolactin]] levels. 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. This artifact is avoided by repeating the assay by dilution of serum. | * “Hook effect” should be kept in consideration while assessing serum [[prolactin]] levels. 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. This artifact is avoided by repeating the assay by dilution of serum. | ||
* Cabergoline is | * Cabergoline is preferred by women who wish to conceive as it is safe in early pregnancy. Though bromocriptine is also a safe choice with more evidence of reduced events of congenital defects. | ||
* Patients with [[hyperprolactinemia]] with normal serum [[prolactin]] levels should be monitored for regular intervals after discontinuing [[cabergoline]]. There is a recurrence of [[hyperprolactinemia]] in these patients. | * Patients with [[hyperprolactinemia]] with normal serum [[prolactin]] levels should be monitored for regular intervals after discontinuing [[cabergoline]]. There is a recurrence of [[hyperprolactinemia]] in these patients. | ||
Revision as of 15:22, 10 August 2020
Associate Editor(s)-in-Chief: Mydah Sajid, MD[1]
Hyperprolactinemia resident survival guide
Overview
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.
Common Causes
- Pregnancy
- Lactation
- Prolactinoma
- Injury to dopaminergic neurons in the hypothalamus (sarcoidosis, craniopharyngioma, and metastatic brain carcinoma)[1]
- Section of the hypothalamic-pituitary stalk
- Antipsychotics (risperidone, haloperidol, and phenothiazine)
- Selective serotonin reuptake inhibitors
- Metoclopramide
- Domperidone
- Methyldopa
- Verapamil
- Familial hyperprolactinemia
- Hypothyroidism
- Chronic renal failure
- macroprolactinomas
- Exercise
Evaluation
Shown below is an algorithm summarizing the diagnosis of hyperprolactinemia according to an Endocrine Society Clinical Practice guidelines:
| Suggestive symptoms including headache, oligomenorrhea, infertility, hypogonadism, erectile dysfunction, and galactorrhea | |||||||||||||||||||
| Detailed history and physical examination should be performed to rule out hypothyroidism, chronic renal failure, and the use of medications known to cause hyperprolactinemia. | |||||||||||||||||||
| 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. | |||||||||||||||||||
| MRI with the contrast of brain should be performed to rule out any mass in the hypothalamic-pituitary region. | |||||||||||||||||||
| 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 | |||||||||||||||||||
Management
Shown below is an algorithm summarizing the treatment of hyperprolactinemia:
The prolactinoma are treated in the following patients:
| |||||||||||||||||||||||||||||||
| 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:
| ||||||||||||||||||||||||||||||
| 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. | |||||||||||||||||||||||||||||||
Do's
- “Hook effect” should be kept in consideration while assessing serum prolactin levels. 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. 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. Though bromocriptine is also a safe choice with more evidence of reduced events of congenital defects.
- Patients with hyperprolactinemia with normal serum prolactin levels should be monitored for regular intervals after discontinuing cabergoline. There is a recurrence of hyperprolactinemia in these patients.
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.
- 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.
References
- ↑ 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.