{"id":568,"date":"2020-02-16T22:01:09","date_gmt":"2020-02-16T16:31:09","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=568"},"modified":"2020-02-16T22:01:09","modified_gmt":"2020-02-16T16:31:09","slug":"management-of-hyperprolactinemia","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/management-of-hyperprolactinemia\/","title":{"rendered":"Management of hyperprolactinemia"},"content":{"rendered":"\n<p><strong>Management of hyperprolactinemia<\/strong><\/p>\n\n\n\n<p>Lactotroph adenomas (prolactinomas)<\/p>\n\n\n\n<p><strong>INDICATIONS FOR TREATMENT<\/strong><\/p>\n\n\n\n<ul><li>existing or impending <strong>neurologic symptoms (such as visual impairment or headache<\/strong>) due to the large size of a lactotroph adenoma, and<\/li><li><strong>hypogonadism<\/strong> or other symptoms due to hyperprolactinemia, such as <strong>galactorrhea.<\/strong><\/li><li>in women with mild hyperprolactinemia and normal cycles who are trying to conceive as they may have subtle luteal phase dysfunction<\/li><\/ul>\n\n\n\n<p><strong>OVERVIEW OF DOPAMINE AGONISTS<\/strong><\/p>\n\n\n\n<p>A dopamine agonist drug should usually be the first treatment for patients with hyperprolactinemia of any cause, including lactotroph adenomas (prolactinomas) of all sizes, because these drugs decrease serum prolactin concentrations and decrease the size of most lactotroph adenomas<\/p>\n\n\n\n<p><strong>Choice of drug<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>For most patients with hyperprolactinemia,&nbsp;cabergoline&nbsp;is our first choice, and&nbsp;bromocriptine&nbsp;is our second.<\/li><li>Pergolide had been used for Parkinson disease and hyperprolactinemia, but it was withdrawn \u00e0 concerns about valvular heart disease.&nbsp;<\/li><li>Quinagolide&nbsp;is available in some countries, but not the United States<\/li><\/ul>\n\n\n\n<p>\u25cfCabergoline&nbsp;\u2013<\/p>\n\n\n\n<ul><li><strong>first choice<\/strong> because of its <strong>efficacy and favorable side-effect profile<\/strong><\/li><li>an ergot dopamine agonist that is administered <strong>once or twice a week<\/strong> and<\/li><li>Dopamine agonists decrease prolactin secretion and reduce the size of the lactotroph adenoma in more than <strong>90 percent of patients.<\/strong> \u00a0<\/li><li>For patients with lactotroph macroadenomas, <strong>no matter how large or how severe the neurologic consequences\u00a0 \u00e0 recommend initial treatment with a dopamine agonist<\/strong>. Dosing is the same as that for microadenomas<\/li><li>Cabergoline\u00a0may be <strong>superior to\u00a0<u>bromocriptine<\/u><\/strong>\u00a0in decreasing the serum prolactin concentration<\/li><li>has much <strong>less tendency to cause nausea<\/strong> than\u00a0bromocriptine\u00a0<\/li><li>may also be effective in <strong>patients resistant to bromocriptine<\/strong><\/li><li>At the high doses used for the treatment of Parkinson disease, cabergoline is associated with <strong>an increased risk of valvular heart disease<\/strong><\/li><li>but at the <strong>lower doses<\/strong> generally used for the treatment of hyperprolactinemia, cabergoline <strong>does not appear to be associated with this risk.<\/strong><\/li><\/ul>\n\n\n\n<p>recommend cabergoline as the <strong>initial choice of dopamine agonists<\/strong> in most circumstances because it is most likely to be effective and least likely to cause side effects<\/p>\n\n\n\n<p>Because of the association between high-dose\u00a0cabergoline\u00a0use for Parkinson disease and valvular heart disease, we suggest using the lowest dose of cabergoline necessary to lower prolactin to normal<\/p>\n\n\n\n<p>For patients who require <strong>higher than usual doses<\/strong> of cabergoline (eg, greater than 2 mg per week), we suggest <strong>cardiac ultrasonography every two years<\/strong><\/p>\n\n\n\n<p>If bromocriptine is used first and the patient cannot tolerate it or serum prolactin concentrations do not normalize, we suggest <strong>switching to cabergoline<\/strong><\/p>\n\n\n\n<p>In women with <strong>lactotroph microadenomas seeking fertility<\/strong> whose serum <strong>prolactin concentrations do not normalize with dopamine agonist therapy<\/strong> (and who therefore do not ovulate), we suggest <strong>ovulation induction with clomiphene citrate or gonadotropin therapy<\/strong><\/p>\n\n\n\n<p>Bromocriptine&nbsp;\u2013<\/p>\n\n\n\n<ul><li><strong>given twice a day<\/strong> to have optimal therapeutic effect<\/li><li>more likely to cause nausea than&nbsp;cabergoline.<\/li><\/ul>\n\n\n\n<p><strong>Actions of bromocriptine are:<\/strong><\/p>\n\n\n\n<p>1. Decreases prolactin release from pituitary and is a strong antigalactopoietic.<\/p>\n\n\n\n<p>2. Increases GH release in normal individuals, but decreases the same from pituitary tumours that cause acromegaly.<\/p>\n\n\n\n<p>3. Has levodopa like actions in CNS- antiparkinsonian and behavioural effects.<\/p>\n\n\n\n<p>4. Produces nausea and vomiting by stimulating dopaminergic receptors in the CTZ.<\/p>\n\n\n\n<p>5. Hypotension- due to central suppression of postural reflexes and weak peripheral a adrenergic blockade.<\/p>\n\n\n\n<p>6. Decreases gastrointestinal motility.<\/p>\n\n\n\n<p>The therapeutic efficacy of dopamine agonists may be blunted by the concurrent use of drugs known to raise serum prolactin concentrations, including neuroleptic drugs,&nbsp;metoclopramide, domperidone,&nbsp;methyldopa,&nbsp;verapamil, and&nbsp;cimetidine.<\/p>\n\n\n\n<p><strong>Time course of clinical response<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>The fall in serum prolactin \u00e0 within the first two to three weeks of therapy.<\/li><li>The decrease in adenoma size can, in many patients, be detected by imaging within six weeks after initiation of treatment<\/li><li>Following the decrease in serum prolactin and adenoma size in patients with macroadenomas \u00e0 visual and pituitary function often return to normal.<\/li><li>Vision usually begins to improve within days after the initiation of treatment<\/li><li>There is recovery of menses and fertility in women and of testosterone secretion, sperm count, and erectile function in men<\/li><\/ul>\n\n\n\n<p><strong>Adverse effects<\/strong>&nbsp;\u2014&nbsp;<\/p>\n\n\n\n<ul><li>nausea, postural hypotension, and mental fogginess.<\/li><li>Less common side effects include nasal stuffiness, depression, Raynaud phenomenon, alcohol intolerance, and constipation.<\/li><li>Nausea appears to be more common with&nbsp;bromocriptine&nbsp;than&nbsp;cabergoline.<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Management of hyperprolactinemia Lactotroph adenomas (prolactinomas) INDICATIONS FOR TREATMENT existing or impending neurologic symptoms (such as visual impairment or headache) due to the large size of a lactotroph adenoma, and hypogonadism or other symptoms due to hyperprolactinemia, such as galactorrhea. in women with mild hyperprolactinemia and normal cycles who are trying to conceive as they[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/568"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=568"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/568\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=568"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=568"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=568"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}