[Misleading diagnosis of hyperprolactinemia in women]

Efficacy of Metformin-Cabergoline Compared to Metformin Monotherapy for Management of PCOS With Hyperprolactinemia: A Systematic Review and Meta-analysis

Background

Metformin plays a major part in the treatment of polycystic ovarian syndrome .Trials are being conducted to compare the effectiveness of combination of metformin with cabergoline in the treatment of hyperprolactinemia and polycystic ovarian syndrome.

Objectives

The purpose of this study is to compare the effectiveness of metformin monotherapy and combination therapy with cabergoline versus metformin for the management of polycystic ovarian syndrome with hyperprolactinemia.

Methodology

An extensive search up until 31 May 2024 of electronic databases (PubMed, Registry of Controlled Clinical Trials, Web of Sciences, SCOPUS) to find pertinent studies. An analysis was conducted with both observational data and randomized clinical trials . To compute the standard mean difference, weighted mean difference, odds ratio, and 95% confidence interval, RevMan (v5.3) was utilized. Primary outcomes that were assessed included body-mass index, regular menstruation, weight change, prolactin, testosterone, and dehydroepiandrosterone-sulfate levels.

Results

Three randomized controlled trials and 1 observational study, taking a total patient population of n = 535, were part of our final analysis. Prolactin (SMD = -3.23 95% CI: (-4.90, -1.55)) and dehydroepiandrosterone-sulfate levels (SMD = -0.27 95% CI: (-0.52, -0.01)) were significantly lower in the metformin and cabergoline combination therapy group; monthly regularity was also significantly higher (OR = 3.07 95% CI: (2.09, 4.51)). Statistically, there was no significant difference in weight, body-mass index, or testosterone levels.

Conclusions

In the treatment of polycystic ovarian syndrome, the combination of metformin and cabergoline significantly lowers prolactin levels and encourages regular menstrual cycles. Although metformin has the potential to suppress testosterone levels, more investigation is required to determine how combination therapy affect dehydroepiandrosterone-sulfate and testosterone levels. It's interesting to note that while neither intervention had a substantial impact on weight or body-mass index, metformin and cabergoline combination therapy outperformed metformin monotherapy in terms of supporting regular menstrual cycles. Customized therapy approaches are essential, and large-scale trials involving a variety of groups are required to comprehend the safety and effectiveness of treatments.

Persistent Idiopathic Prolactin Elevation Merits Macroprolactin Estimation: A Case Report and Review of Literature

The prevalence of hyperprolactinemia ranges from about 0.4% in an unselected adult population to as high as 9%–17% in women with reproductive disorders. It may cause infertility in about 11% of the oligospermic males. Rarely, the cause of persistently elevated prolactin remains obscure even after thorough work up. Macroprolactinemia is biologically inactive, high-molecular-weight form of prolactin resulting from its binding to immunoglobulin G, causing a decrease in its clearance. We report the case of a 35-year-old female, detected to have hyperprolactinemia on multiple tests, during routine work up for primary infertility. Secondary causes for the same were ruled out. A magnetic resonance imaging (MRI) of the brain excluded a prolactinoma. This prompted an estimation of prolactin levels after polyethylene glycol precipitation which showed a decrease to 5.58 ng/mL, with <40% recovery, confirming the presence of macroprolactin. Thus, persistently elevated prolactin levels in the background of negative neurological imaging necessitate the estimation of macroprolactin.

Role of prolactin/adenoma maximum diameter and prolactin/adenoma volume in the differential diagnosis of prolactinomas and other types of pituitary adenomas

The present study aimed to investigate the function of the prolactin/adenoma maximum diameter (PRL/MD) and the prolactin/adenoma volume (PRL/V) in the differential diagnosis of prolactinomas and other types of pituitary adenomas. A total of 118 patients with pituitary adenoma, hyperprolactinemia and a plasma PRL <250 µg/l were enrolled. Clinical data from these patients were retrospectively analyzed. A receiver operating characteristic curve was plotted. The function of PRL, PRL/MD and PRL/V in the differential diagnosis of prolactinomas and other types of pituitary adenomas was compared. The results revealed that a PRL of 55.65 µg/l was the most accurate [sensitivity (SE), 0.800; specificity (SP), 0.716; positive predictive value (PPV), 0.857; negative predictive value (NPV), 0.933; and Youden index (YI), 0.516]. The PRL/MD with the highest diagnostic value was 4.03 µg/(l × mm) (SE, 0.800; SP, 0.898; PPV, 0.727; NVP, 0.929; and YI, 0.698). The PRL/V with the highest diagnostic value was 54.00 µg/(l × cm³) (SE, 0.900; SP, 0.966; PPV, 0.900; NVP, 0.966; and YI, 0.866). The PRL/MD tended to be of higher diagnostic accuracy than PRL, but this difference was not statistically significant (P=0.097). The differentiation ability of PRL/V was significantly stronger than that of PRL (P=0.028). Thus, serum PRL, PRL/MD and PRL/V levels may be able to differentiate prolactinomas from other types of hyperprolactinemia-causing pituitary adenomas prior to treatment. PRL/V may be better than the PRL level in achieving a differential diagnosis, and the optimal PRL/V ratio for differentiating prolactinomas from other types of hyperprolactinemia-causing pituitary adenomas was 54.00 µg/(l × cm³).

Efficacy of Combined Cabergoline and Metformin Compared to Metformin Alone on Cycle Regularity in Patients with Polycystic Ovarian Disease with Hyperprolactinemia: A Randomized Clinical Trial

PURPOSE

Polycystic ovarian syndrome (PCOS) is a common reproductive disorder. Increasing serum prolactin in these patients could be detected in both follicular and luteal phase of the normal and stimulated cycles. Hyperprolactinemia affects the hypothalamic-pituitary-ovarian axis causing anovulation and abnormal uterine bleeding. In this study, the efficacy of combined cabergoline and metformin therapy was compared to metformin therapy alone in patients with PCOS on the body mass index, androgen profile and menstrual cycle regulation.

METHODS

Two hundred and fifty patients with polycystic ovarian syndrome (PCOS) with increased serum prolactin were randomly allocated into two groups: group (1) received oral metformin tablet 1000 mg per day and cabergoline 0.5 g tablet weekly for 3 months as a case group, and group (2) received oral metformin tablet 1000 mg per day and a placebo tablet weekly for 3 months as the control group (n = 123). Body mass index (BMI), menstrual cycle regularity, serum testosterone, serum prolactin and dehydroepiandrosterone sulfate (DHEAS) level were compared before and after treatment in both groups.

RESULTS

There was significant decrease in body mass index and improvement of androgenic profile in both groups after treatment. In group (1), there was significant improvement in cycle regularity and significant decrease in serum prolactin level post-treatment.

CONCLUSIONS

The use of cabergoline in addition to metformin had more favorable effect on cycle regularity and prolactin level in patients with polycystic ovarian syndrome with hyperprolactinemia than the use of metformin alone.