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Benetti-Pinto CL, Nácul AP, Rosa E Silva ACJ, Maciel GAR, Dos Santos Nunes Nogueira V, Elias PCL, Martins M, Kasuki L, Garmes HM, Glezer A. Hyperprolactinemia in women: treatment. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-FPS05. [PMID: 38765515 PMCID: PMC11078113 DOI: 10.61622/rbgo/2024fps05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Cristina Laguna Benetti-Pinto
- Universidade Estadual de Campinas Faculdade de Ciências Médicas Departamento de Obstetrícia e Ginecologia CampinasSP Brazil Departamento de Obstetrícia e Ginecologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Unicamp, Campinas, SP, Brazil
| | - Andrea Prestes Nácul
- Unidade de Reprodução Humana Hospital Fêmina Grupo Hospitalar Conceição Porto AlegreRS Brazil Unidade de Reprodução Humana, Hospital Fêmina, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Ana Carolina Japur Rosa E Silva
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Departamento de Ginecologia e Obstetrícia Ribeirão PretoSP Brazil Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Gustavo Arantes Rosa Maciel
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas HCFMUSP Sao PauloSP Brazil Departamento de Obstetrícia e Ginecologia, Disciplina de Ginecologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Vania Dos Santos Nunes Nogueira
- Universidade Estadual Paulista Faculdade de Medicina de Botucatu Departamento de Clínica Médica BotucatuSP Brazil Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil
| | - Paula Condé Lamparelli Elias
- Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto Hospital das Clínicas São PauloSP Brazil Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Manoel Martins
- Universidade Federal do Ceará Núcleo de Pesquisa e Desenvolvimento de Medicamentos Departamento de Medicina Clínica FortalezaCE Brazil Departamento de Medicina Clínica e Núcleo de Pesquisa e Desenvolvimento de Medicamentos, Universidade Federal do Ceará, Fortaleza, CE, Brazil
| | - Leandro Kasuki
- Universidade Federal do Rio de Janeiro Hospital Universitário Clementino Fraga Filho Rio de JaneiroRJ Brazil Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Heraldo Mendes Garmes
- Universidade Estadual de Campinas Faculdade de Ciências Médicas CampinasSP Brazil Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Andrea Glezer
- Universidade de São Paulo Hospital das Clínicas Faculdade de Medicina São PauloSP Brazil Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Benetti-Pinto CL, Prestes Nácul A, Rosa-E-Silva ACJDS, Maciel GAR, Dos Santos Nunes Nogueira V, Condé Lamparelli Elias P, Martins M, Kasuki L, Mendes Garmes H, Glezer A. Treatment of hyperprolactinemia in women: A Position Statement from the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and the Brazilian Society of Endocrinology and Metabolism (SBEM). ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230504. [PMID: 38578473 PMCID: PMC11081053 DOI: 10.20945/2359-4292-2023-0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/20/2024] [Indexed: 04/06/2024]
Abstract
Dopamine agonists are the first line of treatment for patients with symptomatic hyperprolactinemia due to prolactinomas and in those with idiopathic hyperprolactinemia. Treatment with these agents is effective in 80%-90% of the cases. Infertility treatment of patients with hyperprolactinemia is also carried out with dopamine agonists, aiming for the normalization of prolactin levels. The risk of symptomatic growth of prolactinomas during pregnancy is dependent on the tumor's size, duration of previous treatments, and prolactin levels. Notably, the corresponding risk is relatively low in cases of microprolactinomas (<5%). Remission of hyperprolactinemia occurs in about 30% of the patients after drug treatment and may also occur after pregnancy and menopause. The use of some drugs, such as antidepressants and antipsychotics, is a frequent cause of hyperprolactinemia, and managing this occurrence involves unique considerations. This position statement by the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo) and Brazilian Society of Endocrinology and Metabolism (SBEM) addresses the recommendations for measurement of serum prolactin levels and the investigations of symptomatic and asymptomatic hyperprolactinemia and drug-induced hyperprolactinemia in women.
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Affiliation(s)
- Cristina Laguna Benetti-Pinto
- Departamento de Obstetrícia e Ginecologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brasil
| | - Andrea Prestes Nácul
- Unidade de Reprodução Humana, Hospital Fêmina, Grupo Hospitalar Conceição, Porto Alegre, RS, Brasil
| | | | - Gustavo Arantes Rosa Maciel
- Departamento de Obstetrícia e Ginecologia, Disciplina de Ginecologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Paula Condé Lamparelli Elias
- Departamento de Clínica Médica, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Manoel Martins
- Departamento de Medicina Clínica e Núcleo de Pesquisa e Desenvolvimento de Medicamentos, Universidade Federal do Ceará, Fortaleza, CE, Brasil
| | - Leandro Kasuki
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Heraldo Mendes Garmes
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brasil
| | - Andrea Glezer
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil,
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Carneiro MS, de Mira TAA, Yela DA, Benetti-Pinto CL. Prolactinoma in postmenopausal women: a systematic review. Menopause 2024; 31:160-167. [PMID: 38194617 DOI: 10.1097/gme.0000000000002303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
IMPORTANCE Prolactinomas occurring during the reproductive period exhibit a characteristic behavior. There are, however, gaps in the literature regarding the behavior of these tumors after menopause. OBJECTIVE This study aimed to review and characterize the influence of menopause on prolactinoma behavior. EVIDENCE REVIEW A systematic review of observational prospective or retrospective studies and clinical trials on prolactinomas was conducted in two situations: tumors diagnosed in the reproductive period (before menopause), with follow-up in the postmenopausal period, or prolactinomas diagnosed in the postmenopausal period, without language or date restrictions. Data extracted from the articles included patient and tumor characteristics (prolactinoma type, previous treatment, symptoms, and serum prolactin [PRL] levels). FINDINGS This study included five studies comprising 180 participants. Prolactinomas diagnosed in women of reproductive age are treated with dopaminergic agonists (DAs), with indications of treatment withdrawal after menopause, exhibited stable tumor behavior and PRL levels. Considering the diagnosis during the postmenopausal period, macroprolactinomas were more prevalent and showed tumor shrinkage when DAs were used. Cabergoline, the most commonly used drug, lowers PRL levels and reduces symptoms associated with adenoma. CONCLUSIONS AND RELEVANCE Microadenomas diagnosed before menopause can be followed up without treatment. Prolactinomas diagnosed after menopause are typically macroadenomas. Cabergoline remains the treatment of choice in the presence of clinical or compressive symptoms. We recommend at least one annual follow-up for such patients.
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Affiliation(s)
- Marcela Souza Carneiro
- From the Department of Gynecology and Obstetrics, University of Campinas, Campinas, São Paulo, Brazil
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4
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Petersenn S, Fleseriu M, Casanueva FF, Giustina A, Biermasz N, Biller BMK, Bronstein M, Chanson P, Fukuoka H, Gadelha M, Greenman Y, Gurnell M, Ho KKY, Honegger J, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Lodish M, Maiter D, Marcus HJ, McCormack A, Molitch M, Muir CA, Neggers S, Pereira AM, Pivonello R, Post K, Raverot G, Salvatori R, Samson SL, Shimon I, Spencer-Segal J, Vila G, Wass J, Melmed S. Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement. Nat Rev Endocrinol 2023; 19:722-740. [PMID: 37670148 DOI: 10.1038/s41574-023-00886-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/07/2023]
Abstract
This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany.
- University of Duisburg-Essen, Essen, Germany.
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University, Milan, Italy
- IRCCS Hospital San Raffaele, Milan, Italy
| | | | | | | | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Monica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Yona Greenman
- Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Ken K Y Ho
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | | | | | - Ursula B Kaiser
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Maya Lodish
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Hani J Marcus
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Alberto M Pereira
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Kalmon Post
- Mount Sinai Health System, New York, NY, USA
| | - Gerald Raverot
- Department of Endocrinology, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron, France
| | | | | | - Ilan Shimon
- Tel Aviv University, Tel Aviv, Israel
- Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- University of Oxford, Oxford, UK
- Churchill Hospital, Oxford, UK
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Auriemma RS, Pirchio R, Pivonello C, Garifalos F, Colao A, Pivonello R. Approach to the Patient With Prolactinoma. J Clin Endocrinol Metab 2023; 108:2400-2423. [PMID: 36974474 PMCID: PMC10438891 DOI: 10.1210/clinem/dgad174] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/03/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
Prolactinomas are the most common pituitary tumor histotype, with microprolactinomas being prevalent in women and macroprolactinomas in men. Hyperprolactinemia is among the most common causes of hypogonadotropic hypogonadism in both sexes, prompting medical advice for hypogonadism (infertility, oligo-amenorrhea, impotence, osteoporosis/osteopenia) in both sexes, and for signs and symptoms of mass effects (hypopituitarism, visual loss, optic chiasm compression, cranial nerve deficits, headaches) predominantly in men. Diagnostic workup involves a single prolactin measurement and pituitary imaging, but some laboratory artifacts (ie, the "hook effect" and macroprolactin) can complicate or delay the diagnosis. The treatment of choice for prolactinomas is represented by dopamine agonists, mainly cabergoline, which are able to induce disease control, restore fertility in both sexes, and definitively cure one-third of patients, thus permitting treatment discontinuation. Pregnancy and menopause may promote spontaneous prolactin decline and anticipate cabergoline discontinuation in women. Surgery and/or radiotherapy are indicated in case of resistance to cabergoline not overcome by the increase in drug dose up to the maximally tolerated or the patient's personal choice of surgery. The evidence of resistance to cabergoline in invasive and proliferative tumors may indicate biological aggressiveness, thus requiring alternative therapeutic approaches mainly based on temozolomide use as monotherapy or combined with radiotherapy. In uncontrolled patients, new medical approaches (alternative hormonal treatments, cytotoxic drugs, peptide receptor radionuclide therapy, mTOR/Akt inhibitors, tyrosine kinase inhibitors, or immunotherapy) may be offered but the experience collected to date is still very scant. This article reviews different facets of prolactinomas and discusses approaches to the condition in more common clinical situations.
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Affiliation(s)
- Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Sanità Pubblica, Università Federico II di Napoli, 80131 Naples, Italy
| | - Francesco Garifalos
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, 80131 Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, 80131 Naples, Italy
- Unesco Chair for Health Education and Sustainable Development, “Federico II” University, 80131 Naples, Italy
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6
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Cozzi R, Ambrosio MR, Attanasio R, Battista C, Bozzao A, Caputo M, Ciccarelli E, De Marinis L, De Menis E, Faustini Fustini M, Grimaldi F, Lania A, Lasio G, Logoluso F, Losa M, Maffei P, Milani D, Poggi M, Zini M, Katznelson L, Luger A, Poiana C. Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors. Eur J Endocrinol 2022; 186:P1-P33. [PMID: 35000899 PMCID: PMC8859924 DOI: 10.1530/eje-21-0977] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022]
Abstract
Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.
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Affiliation(s)
- Renato Cozzi
- Division of Endocrinology, Niguarda Hospital, Milan, Italy
- Correspondence should be addressed to R Cozzi;
| | - Maria Rosaria Ambrosio
- Section of Endocrinology and Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Claudia Battista
- Endocrinology Unit, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo (FG), Italy
| | - Alessandro Bozzao
- Neuroradiology, S. Andrea Hospital, NESMOS Department (Neuroscience, Mental Health, Sensorial Organs), Sapienza University of Rome, Rome, Italy
| | - Marco Caputo
- Laboratorio Analisi Cliniche e Microbiologia, Synlab SRL, Calenzano, Florence, Italy
| | | | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Catholic University of the Sacred Heart, School of Medicine, Rome, Italy
| | | | | | - Franco Grimaldi
- AME President, Endocrinology and Metabolism Unit, University Hospital S. Maria della Misericordia, Udine, Italy
| | - Andrea Lania
- Department of Biomedical Sciences, Endocrinology Unit, Rozzano, Italy
| | - Giovanni Lasio
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | | | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Maffei
- Department of Medicine (DIMED), 3rd Medical Clinic, Padua University Hospital, Padua, Italy
| | - Davide Milani
- Department of Neurosurgery, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Maurizio Poggi
- Endocrinology, Department of Clinical and Molecular Medicine, S. Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Michele Zini
- Endocrinology Unit, Azienda Ospedaliera S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
| | - Catalina Poiana
- ‘Carol Davila’ University of Medicine and Pharmacy – Endocrinology, “C.I. Parhon” National Institute of Endocrinology – Pituitary and Neuroendocrine Disorders, Bucharest, Romania
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De Sousa SMC. Dopamine agonist therapy for prolactinomas: do we need to rethink the place of surgery in prolactinoma management? ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R31-R50. [PMID: 37435462 PMCID: PMC10259306 DOI: 10.1530/eo-21-0038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 04/20/2022] [Indexed: 07/13/2023]
Abstract
The current treatment paradigm for prolactinomas involves dopamine agonist (DA) therapy as the first-line treatment, with surgical resection reserved for cases where there is DA failure due to resistance or intolerance. This review highlights how DA therapy can be optimised to overcome its increasingly recognised pitfalls, whilst also addressing the potential for expanding the use of surgery in the management of prolactinomas. The first part of the review discusses the limitations of DA therapy, namely: DA resistance; common DA side effects; and the rare but serious DA-induced risks of cardiac valvulopathy, impulse control disorders, psychosis, CSF rhinorrhoea and tumour fibrosis. The second part of the review explores the role of surgery in prolactinoma management with reference to its current second-line position and recent calls for surgery to be considered as an alternative first-line treatment alongside DA therapy. Randomised trials comparing medical vs surgical therapy for prolactinomas are currently underway. Pending these results, a low surgical threshold approach is herein proposed, whereby DA therapy remains the default treatment for prolactinomas unless there are specific triggers to consider surgery, including concern regarding DA side effects or risks in vulnerable patients, persistent and bothersome DA side effects, emergence of any serious risks of DA therapy, expected need for long-term DA therapy, as well as the traditional indications for surgery. This approach should optimise the use of DA therapy for those who will most benefit from it, whilst instituting surgery early in others in order to minimise the cumulative burden of prolonged DA therapy.
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Affiliation(s)
- Sunita M C De Sousa
- Endocrine & Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
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Leshchenko OY. Hyperprolactinemia in the postmenopause: versions and contraversions. TERAPEVT ARKH 2021; 93:1234-1239. [DOI: 10.26442/00403660.2021.10.201073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022]
Abstract
The prevalence of hyperprolactinemia in postmenopausal women is unknown and has been estimated as infrequent by many studies. Prolactinomas found after menopause are usually macroadenomas and remain unrecognized for a long time due to atypical clinical signs or their absence. The growth potential of prolactinomas persists after menopause, most of them are invasive and accompanied by high prolactin levels. Treatment with dopamine agonists is usually long-term, the goals of which are to reduce tumor size, normalize prolactin levels and the negative effects of hyperprolactinemia. Treatment with cabergoline makes it possible to achieve remission of the disease in the first years after discontinuation, however, the proportion of relapses in postmenopausal women increases 5 years after discontinuation of the drug. Remission of prolactinomas is not evident in postmenopausal women. The modern management of patients with prolactinoma and/or hyperprolactinemia does not have clear positions in the postmenopausal period. Controversial issues remain: an ambiguous relationship between prolactin levels and breast cancer, there are no convincing conclusions on the improvement of bone mineral density and/or a decrease in the risk of fractures with normalization of prolactin levels, there are no data on metabolic parameters after the end of treatment with dopamine agonists, conflicting information about the relationship of prolactin levels and the severity of the manifold manifestations of the climacteric syndrome. The use of estrogen-progestin drugs in women with hyperprolactinemia/prolactinomas is also not well understood. Thus, the problem of hyperprolactinemia in the perimenopausal and postmenopausal period is underestimated and requires additional research, as well as the development of diagnostic and therapeutic strategies for potential benefits in terms of weight loss, improving insulin sensitivity, reducing the risk of fractures, maintaining sexuality and psycho-emotional well-being.
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Auriemma RS, Pirchio R, Pivonello R, Colao A. Hyperprolactinemia after menopause: Diagnosis and management. Maturitas 2021; 151:36-40. [PMID: 34446277 DOI: 10.1016/j.maturitas.2021.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/18/2021] [Accepted: 06/25/2021] [Indexed: 01/01/2023]
Abstract
Most prolactinomas are diagnosed in women of reproductive age and are generally microadenomas. Prolactinomas diagnosed in postmenopausal women are less common and are not usually associated with the typical syndrome induced by prolactin excess, including infertility and oligo-amenorrhea. This implies that the diagnosis of prolactinomas after menopause may be delayed and require greater clinical effort. Limited data are available on the management and prognosis of prolactinomas in postmenopausal women. However, the physiologic decline of prolactin levels during menopause and the lack of fertility concerns, which represent specific indications for medical treatment with dopamine agonists, might require a careful reassessment of therapeutic management in such patients. Postmenopausal women with microprolactinoma may be successfully withdrawn from medical therapy with dopamine agonists, whereas in those with macroprolactinomas greater caution is advisable before dopamine agonists are discontinued, considering the potential, although rare, tumor enlargement. This review focuses on the diagnostic challenges and therapeutic management of prolactinomas in postmenopausal women.
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Affiliation(s)
- Renata S Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Rosa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy; Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Unità di Andrologia e Medicina della Riproduzione e Sessualità Maschile e Femminile (FERTISEXCARES), Università Federico II di Napoli, Naples, Italy; Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy; Unesco Chair for Health Education and Sustainable Development, "Federico II" University, Naples, Italy.
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González-Rodríguez A, Labad J, Seeman MV. Antipsychotic-induced Hyperprolactinemia in aging populations: Prevalence, implications, prevention and management. Prog Neuropsychopharmacol Biol Psychiatry 2020; 101:109941. [PMID: 32243999 DOI: 10.1016/j.pnpbp.2020.109941] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/23/2019] [Accepted: 03/29/2020] [Indexed: 12/21/2022]
Abstract
This paper reviews the prevalence, implications, prevention and management of antipsychotic-induced hyperprolactinemia in aging populations. Antipsychotics are indicated mainly for the treatment of psychotic illness but are also used in other conditions. Complications induced by antipsychotics increase with age, due to age-related changes in drug metabolism and excretion. Almost all antipsychotics lead to hyperprolactinemia by blocking dopamine D2 receptors in the anterior pituitary gland, which counteracts dopamine's inhibitory action on prolactin secretion. The main findings of this narrative review are that, though many of the known side effects of high prolactin levels lose their salience with age, the risk of exacerbating osteoporosis remains critical. Methods of preventing antipsychotic-induced hyperprolactinemia in older individuals include using antipsychotic medication (AP) as sparingly as possible and monitoring AP serum levels, regularly measuring prolactin levels, closely monitoring bone density, treating substance abuse, and teaching patients stress management techniques. When hyperprolactinemia symptoms cannot be otherwise managed, adjunctive drugs are available. Potential helpful adjuncts are: dopamine agonists, antipsychotics with partial agonist properties (e.g. aripiprazole), selective estrogen receptor modulators, and metformin. Because a gold standard for prevention/treatment has not been established, clinical decisions need to be made based on safety and individual circumstance.
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Affiliation(s)
- Alexandre González-Rodríguez
- Department of Mental Health. Parc Tauli University Hospital. I3PT. Sabadell (Barcelona, Spain) Autonomous University of Barcelona (UAB)..
| | - Javier Labad
- Department of Mental Health. Parc Tauli University Hospital. I3PT. Sabadell (Barcelona, Spain) Autonomous University of Barcelona (UAB). CIBERSAM
| | - Mary V Seeman
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada, M5P 3L6
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11
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Abstract
Hyperprolactinemia is associated with suppression of the hypothalamic- pituitary-gonadal axis and consequent hypogonadism, manifesting loss of libido, infertility and osteoporosis long-term in both male and female patients, with associated menstrual irregularities, amenorrhea and galactorrhea in women and erectile dysfunction in men. The primary goals of therapy in patients harboring prolactinoma are control of tumor size and normalization of serum PRL, with restoration of gonadal and sexual function and fertility. Clinical manifestations of hypogonadism have variable consequences depending on the age and sex of the patient and desire for fertility. Careful consideration of clinical consequences of hyperprolactinemia in relation to age and sex should help guide therapeutic decision making. Another important consideration in attaining our treatment goals in patients harboring microprolactinomas, is the observation that greater than 90% of microprolactinomas do not enlarge, when followed for 10 years. Treatment options for the management of microprolactinomas include observation alone, with monitoring of serum prolactin levels every 6-12 months, vs initiation of dopamine agonist therapy vs gonadal steroid hormone replacement (using the oral contraceptive or other combination estrogen and progesterone replacement regimens in females or testosterone replacement therapy in males). In the present review, current data related to clinical consequences of microprolactinomas and treatment outcomes at different stages in the lifespan are reviewed, with a suggested algorithm as to whether to treat or not, and an appropriate therapeutic regimen to institute.
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Affiliation(s)
- Vivien Bonert
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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12
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Abstract
PURPOSE Treatment goals in prolactinomas are to correct hypogonadism, restore fertility and control tumor mass in case of macroadenomas. According to current guidelines, medical treatment of asymptomatic postmenopausal women is not indicated. The purpose of this study was to review the current literature pertaining to biological behavior of prolactinomas during menopause, likelihood of successful dopamine agonist withdrawal during this period and possible prolactin-mediated increased morbidity that could modify current management. METHODS A comprehensive literature search including papers published until July 2019 was conducted using PubMed and Medline databases. RESULTS Women with prolactinomas entering menopause have a higher chance of prolactin normalization of treatment compared with women in their reproductive years. Although most prolactin secreting adenomas diagnosed during menopause are large, they respond well to dopamine agonist treatment. Data directly linking hyperprolactinemia with an increased risk of cancer and cardiovascular and metabolic morbidity are inconsistent. There is no data indicating that correction of hyperprolactinemia improves clinical outcomes in asymptomatic patients bearing microadenomas. CONCLUSION There is no evidence that justifies changing current recommendations to withhold medical treatment of microprolactinomas in asymptomatic post-menopausal women. Macroprolactinoma patients should be treated according to standard clinical practice.
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Affiliation(s)
- Yona Greenman
- Institute of Endocrinology, Metabolism, Diabetes and Hypertension, Tel Aviv-Sourasky Medical Center, 6 Weizmann Street, 64239, Tel Aviv, Israel.
- Tel Aviv University, Tel Aviv, Israel.
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13
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Cabergoline Withdrawal Before and After Menopause: Outcomes in Microprolactinomas. Discov Oncol 2019; 10:120-127. [PMID: 31001736 DOI: 10.1007/s12672-019-00363-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022] Open
Abstract
Natural course of prolactinomas after menopause is not fully elucidated. The aim of this study was to compare recurrence rate after cabergoline withdrawal in premenopausal vs. postmenopausal women with microprolactinoma. Sixty-two women with microprolactinoma treated with cabergoline for at least 1 year and followed for 2 years after drug withdrawal were retrospectively selected. Patients were divided into two groups: 48 patients stopped cabergoline before menopause ("PRE" group), while 14 after menopause ("POST" group). Recurrence was defined by prolactin levels above normal, confirmed on two occasions. Overall, 39/62 women relapsed. Patients who relapsed apparently had higher prolactin before withdrawal (median 216.2, range 21.2-464.3 mIU/L) compared with those in long-term remission (94.3, 29.7-402.8 mIU/L; p < 0.05), and the risk of recurrence seemed lower in POST women (4/14, 29%) than in PRE ones (35/48, 73%, p < 0.005, OR 0.149, 95% CI 0.040-0.558). However, none of the factors (prolactin before withdrawal, menopausal status, treatment duration, complete adenoma regression) showed a correlation with recurrence risk in multivariate analysis. The best strategy able to optimize CBG treatment and withdrawal's outcomes is still to be defined in microprolactinomas. Postmenopausal status cannot reliably predict long-term remission, and follow-up is needed also in women of this age.
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14
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Vroonen L, Daly AF, Beckers A. Epidemiology and Management Challenges in Prolactinomas. Neuroendocrinology 2019; 109:20-27. [PMID: 30731464 DOI: 10.1159/000497746] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/06/2019] [Indexed: 11/19/2022]
Abstract
Clinically relevant pituitary adenomas are present in about 1 per 1,000 of the general population and prolactinomas are by far the most common clinical subtype of pituitary adenomas. Usually prolactinomas affect premenopausal women and present with typical symptoms of menstrual disturbance and/or galactorrhea. They are generally managed with dopamine agonists to restore fertility and to control symptoms and tumor size. In a subset of prolactinomas, however, management remains challenging. Studies in recent years have identified the factors related to dopamine agonist resistance, such as male sex, genetic features, and aggressive tumor behavior. Certain other patient groups represent particular challenges for management, such as pediatric patients and pregnant women. Treatment with dopamine agonists is usually safe and effective, and adverse effects such as clinically relevant cardiac valvular complications and impulse control disorders may occur in isolated instances. A number of important disease characteristics of prolactinomas remain to be explained, such as the difference in sex prevalence before and after menopause, the higher prevalence of macroadenomas in older males, and the biochemical mechanisms of resistance to dopaminergic agonists.
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Affiliation(s)
- Laurent Vroonen
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Adrian F Daly
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium,
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15
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Pekić S, Medic Stojanoska M, Popovic V. Hyperprolactinemia/Prolactinomas in the Postmenopausal Period: Challenges in Diagnosis and Management. Neuroendocrinology 2019; 109:28-33. [PMID: 30347396 DOI: 10.1159/000494725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022]
Abstract
Hyperprolactinemia is not a common finding in postmenopausal women. Prolactinomas detected after menopause are usually macroadenomas. Due to atypical clinical features they may remain unrecognized for a long period of time. Interestingly the growth potential of prolactinomas remains after menopause. Most tumors are invasive and present with high prolactin levels. They respond to medical treatment with dopamine agonists in terms of prolactin normalization, tumor shrinkage, and improvement in pituitary function. Treatment with dopamine agonists is usually long term. Reducing doses of cabergoline to the lowest that keeps prolactin levels normal prior to withdrawal is proposed to patients with macroprolactinomas who normalize prolactin after > 5 years of treatment and who do not have cavernous sinus invasion. Cabergoline can achieve a high percentage of remission maintenance in the first years after withdrawal. However, the percentage of relapse-free patients 5 years after withdrawal is significantly lower. Besides recurrent hyper-prolactinemia in a subgroup of macroprolactinomas after a long-interval tumor regrowth may be detected. Menopause cannot ensure remission of the tumor so long-term surveillance is suggested. In patients with microadenomas data on long-term remission rates (normalization of prolactin and disappearance of the tumor) after suspension of treatment with dopamine agonists are highly variable. The current strategy for microprolactinomas is not to treat hyperprolactinemia in menopause if it recurrs after discontinuation of dopamine agonists. This is based on: (1) reports that elevated prolactin levels may normalize in some women after menopause, (2) the fact that the association between prolactin levels and breast cancer is inconsistent in postmenopausal women, (3) the lack of clinical evidence that normalization of prolactin levels in postmenopausal women improves bone mineral density or reduces the risk of fracture, and (4) the fact that, concerning the metabolic syndrome, no data are available on metabolic parameters after suspension of treatment with dopamine agonists. For a change in strategy, i.e., for the potential benefits from treatment of hyperprolactinemia in the postmenopausal period with dopamine agonists concerning weight loss, improved insulin sensitivity, decreased fracture risk, and improved sexuality, more evidence is needed.
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Affiliation(s)
- Sandra Pekić
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Endocrinology, Diabetes and Diseases of Metabolism, University Clinical Center, Belgrade, Serbia
| | - Milica Medic Stojanoska
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Vera Popovic
- School of Medicine, University of Belgrade, Belgrade, Serbia,
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16
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Santharam S, Fountas A, Tampourlou M, Arlt W, Ayuk J, Gittoes N, Toogood A, Karavitaki N. Impact of menopause on outcomes in prolactinomas after dopamine agonist treatment withdrawal. Clin Endocrinol (Oxf) 2018; 89:346-353. [PMID: 29894000 DOI: 10.1111/cen.13765] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/04/2018] [Accepted: 06/10/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Discontinuation of dopamine agonist (DA) treatment in women with prolactinoma after menopause is a potential approach; studies systematically assessing long-term outcomes are lacking. Our aim was to investigate the natural history of prolactinoma in this group. DESIGN/PATIENTS Retrospective cohort study of women with prolactinoma diagnosed before menopause and who after menopause were not on DA. RESULTS Thirty women were included. Twenty-eight received DA (median duration 18 years, median age at DA withdrawal 52 years). At last assessment (median follow-up 3 years) and compared with values 6-12 months after stopping DA, Prolactin (PRL) increased in 15%, decreased but not normalized in 33% and was normal in 52%; PRL levels or visible adenoma on imaging before DA withdrawal, treatment duration and presence of macro-/microadenoma at diagnosis were not predictors of normoprolactinaemia at last review, whereas PRL values 6-12 months after stopping DA were. Adenoma regrowth was detected in 2/27 patients (7%), who showed gradual increase in PRL. Comparison with 28 women who had DA withdrawal before their menopause revealed lower risk of hyperprolactinaemia recurrence in the postmenopausal group (HR:0.316, 95% CI: 0.101-0.985, P < .05). Two women with microprolactinoma diagnosed in perimenopausal period had not been offered DA; PRL decreased (but not normalized) during observation of 1 and 8 years. CONCLUSIONS Prolactin normalized over time in nearly half of the women and serum PRL 6-12 months after DA withdrawal is useful predictor. Nonetheless, 7% of the patients demonstrated adenoma regrowth which, given the life expectancy postmenopause, necessitate regular monitoring of the cases with persistent hyperprolactinaemia.
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Affiliation(s)
- Sandhya Santharam
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Athanasios Fountas
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Metaxia Tampourlou
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Neil Gittoes
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Toogood
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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17
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Vilar L, Abucham J, Albuquerque JL, Araujo LA, Azevedo MF, Boguszewski CL, Casulari LA, Cunha Neto MBC, Czepielewski MA, Duarte FHG, Faria MDS, Gadelha MR, Garmes HM, Glezer A, Gurgel MH, Jallad RS, Martins M, Miranda PAC, Montenegro RM, Musolino NRC, Naves LA, Ribeiro-Oliveira Júnior A, Silva CMS, Viecceli C, Bronstein MD. Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:236-263. [PMID: 29768629 PMCID: PMC10118988 DOI: 10.20945/2359-3997000000032] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/09/2017] [Indexed: 11/23/2022]
Abstract
Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.
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Affiliation(s)
- Lucio Vilar
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Julio Abucham
- Unidade de Neuroendócrino, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil
| | - José Luciano Albuquerque
- Serviço de Endocrinologia, Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brasil
| | - Luiz Antônio Araujo
- Centro de Endocrinologia e Diabetes de Joinville (Endoville), Joinville, SC, Brasil
| | - Monalisa F Azevedo
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Cesar Luiz Boguszewski
- Serviço de Endocrinologia e Metabologia, Hospital de Clínicas, Universidade Federal do Paraná (SEMPR), Curitiba, PR, Brasil
| | - Luiz Augusto Casulari
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | - Malebranche B C Cunha Neto
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Mauro A Czepielewski
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Felipe H G Duarte
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manuel Dos S Faria
- Serviço de Endocrinologia, Hospital Universitário Presidente Dutra, Universidade Federal do Maranhão (UFMA), São Luís, MA, Brasil
| | - Monica R Gadelha
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil.,Unidade de Neuroendocrinologia, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, RJ, Brasil
| | - Heraldo M Garmes
- Departamento de Clínica Médica, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (FCM/Unicamp), Campinas, SP, Brasil
| | - Andrea Glezer
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Maria Helane Gurgel
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Raquel S Jallad
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
| | - Manoel Martins
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Paulo A C Miranda
- Serviço de Endocrinologia e Metabologia, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Renan M Montenegro
- Serviço de Endocrinologia, Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFCE), Fortaleza, CE, Brasil
| | - Nina R C Musolino
- Divisão de Neurocirurgia Funcional, Instituto de Psiquiatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (IPq-HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana A Naves
- Serviço de Endocrinologia do Hospital Universitário de Brasília, Universidade de Brasília (UnB), Brasília, DF, Brasil
| | | | - Cíntia M S Silva
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (HUCFF-UFRJ), Rio de Janeiro, RJ, Brasil
| | - Camila Viecceli
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, PPG Endocrinologia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Marcello D Bronstein
- Serviço de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brasil
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18
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Cocks Eschler D, Javanmard P, Cox K, Geer EB. Prolactinoma through the female life cycle. Endocrine 2018; 59:16-29. [PMID: 29177641 DOI: 10.1007/s12020-017-1438-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/22/2017] [Indexed: 12/27/2022]
Abstract
Prolactinomas are the most common secretory pituitary adenoma. They typically occur in women in the 3rd-6th decade of life and rarely in the pediatric population or after menopause. Most women present with irregular menses and/or infertility. Dopamine (DA) agonists, used in their treatment, are safe during pregnancy, but in most cases are discontinued at conception with close monitoring for signs or symptoms of tumor growth. Breastfeeding is safe postpartum, provided there was no significant growth during pregnancy. Some women will experience normalization of prolactin levels postpartum. Menopause may also decrease prolactin levels and even those with macroprolactinomas may consider discontinuing their DA agonist with close follow-up. Prolactinomas may be associated with decreased quality of life scores in women, and play a role in bone health and cardiovascular risk factors. This review discusses the current literature and clinical understanding of prolactinomas throughout the entirety of the female life cycle.
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Affiliation(s)
- Deirdre Cocks Eschler
- Department of Medicine, Division of Endocrinology and Metabolism, SUNY Stony Brook School of Medicine, 26 Research Way, East Setauket, New York, NY, 11733, USA
| | - Pedram Javanmard
- Department of Medicine, Division of Endocrine, Diabetes, and Bone Disease, Icahn School of Medicine at The Mount Sinai Hospital, 1 Gustave L Levy Place box 1055, New York, NY, 10029, USA
| | - Katherine Cox
- Department of Medicine, Division of Endocrine, Diabetes, and Bone Disease, Icahn School of Medicine at The Mount Sinai Hospital, 1 Gustave L Levy Place box 1055, New York, NY, 10029, USA
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 419, New York, NY, 10065, USA.
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Santharam S, Tampourlou M, Arlt W, Ayuk J, Gittoes N, Toogood A, Webster R, Karavitaki N. Prolactinomas diagnosed in the postmenopausal period: Clinical phenotype and outcomes. Clin Endocrinol (Oxf) 2017. [PMID: 28626987 DOI: 10.1111/cen.13399] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Most prolactinomas in females are diagnosed during the reproductive age, and the majority are microadenomas. Prolactinomas detected in the postmenopausal period are less common with limited published data on their presentation and prognosis. Our objective was to assess the presenting clinical, biochemical and imaging findings, as well as the outcomes of women diagnosed with a prolactinoma in the postmenopausal period. DESIGN AND METHODS We undertook a retrospective cohort study of women diagnosed with prolactinoma after menopause and followed up in a large UK pituitary centre. Information on presentation, management and outcomes was collected. RESULTS Seventeen women with a median age at diagnosis of 63 years (range 52-78) were identified. Headaches and/or visual deterioration were the most commonly reported complaints at detection of the adenoma (47%). Acute pituitary apoplexy was diagnosed at presentation or during follow-up in 18% of the cases. The median serum prolactin was 12 364 mU/L (range 2533-238 479). Macroprolactinomas comprised 94% of the tumours, and 88% of them had supra/parasellar extension. All patients with macroprolactinoma were offered dopamine agonist, and normal prolactin was achieved in 94% of them (median follow-up 91.5 months). Adenoma shrinkage was observed in all women. Improvement or resolution of visual disturbances documented at presentation was observed in 86% of cases. CONCLUSIONS The clinical phenotype of prolactinomas diagnosed in the postmenopausal period is characterized by dominance of macroadenomas, with frequent supra/parasellar extension and a relative high rate of acute pituitary apoplexy. In this group of patients, the response of the macroadenomas to dopamine agonists is good.
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Affiliation(s)
- Sandhya Santharam
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Metaxia Tampourlou
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Neil Gittoes
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Andrew Toogood
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Rachel Webster
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Biochemistry, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
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Hyperprolactinaemia - a problem in patients from the reproductive period to the menopause. MENOPAUSE REVIEW 2017; 16:1-7. [PMID: 28546800 PMCID: PMC5437053 DOI: 10.5114/pm.2017.67364] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/07/2017] [Indexed: 01/31/2023]
Abstract
Hyperprolactinaemia especially affects women in reproductive age (90/100,000) but also often is diagnosed in menopause age and leads to disturbances in functioning of LH-RH neurons and, as a consequence, to a decrease of FSH and LH, which causes inhibition of oestradiol production. Prolactin is a peptide hormone, phylogenetically one of the oldest, stimulating cells of various organs, which is produced and secreted mainly by lactotrophic acidophilic cells of the anterior lobe of the pituitary. It influences the increase in the mass of the mammary glands, and stimulation and maintenance of lactation after delivery. There are a number of factors apart of pregnancy, delivery, and lactation than can influence secretion of the hormone in other physiological and pathological circumstances, like high-protein diet, stress, REM sleep, or neoplastic tumours, inflammatory diseases, chronic systematic diseases, thyroid hormonal changes, and drug intake. The purpose of this review is to summarise the current knowledge regarding the proper diagnosis and possible influence of hyperprolactinaemia on fertility and menopause symptoms and current treatment methods.
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Mallea-Gil MS, Manavela M, Alfieri A, Ballarino MC, Chervin A, Danilowicz K, Diez S, Fainstein Day P, García-Basavilbaso N, Glerean M, Guitelman M, Katz D, Loto MG, Martinez M, Miragaya K, Moncet D, Rogozinski AS, Servidio M, Stalldecker G, Vitale M, Boero L. Prolactinomas: evolution after menopause. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:42-6. [PMID: 26909481 PMCID: PMC10118912 DOI: 10.1590/2359-3997000000138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 11/01/2015] [Indexed: 11/22/2022]
Abstract
OBJETIVE The aim was to assess the evolution of tumor size and prolactin (PRL) levels in patients with micro and macroprolactinomas diagnosed and treated with dopamine agonists during fertile age, and the effects of suspension of drugs after menopause. SUBJECTS AND METHODS Retrospective study, 29 patients with prolactinomas, 22 microadenomas and 7 macroadenomas, diagnosed during their fertile age were studied in their menopause; treatment was stopped in this period. Age at menopause was 49 ± 3.6 years. The average time of treatment was 135 ± 79 months. The time of follow-up after treatment suspension was 4 to 192 months. Results: Pre-treatment PRL levels in micro and macroadenomas were 119 ± 57 ng/mL and 258 ± 225 ng/mL, respectively. During menopause after treatment suspension, and at the latest follow-up: in microadenomas PRL levels were 23 ± 13 ng/mL and 16 ± 5.7 ng/mL, respectively; in macroadenomas, PRL levels were 20 ± 6.6 ng/mL 5t5and 25 ± 18 ng/mL, respectively. In menopause after treatment suspension, the microadenomas had disappeared in 9/22 and had decreased in 13/22. In the group of patients whose tumor had decreased, in the latest follow-up, tumors disappeared in 7/13 and remained unchanged in 6/13. In macroadenomas, after treatment suspension 3/7 had disappeared, 3/7 decreased and 1/7 remained unchanged. In the latest control in the 3 patients whose tumor decreased, disappeared in 1/3, decreased in 1/3 and there was no change in the remaining. CONCLUSIONS Normal PRL levels and sustained reduction or disappearance of adenomas were achieved in most of patients, probably due to the decrease of estrogen levels. Dopamine agonists might be stopped after menopause in patients with prolactinomas.
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Affiliation(s)
- Maria Susana Mallea-Gil
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marcos Manavela
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Analia Alfieri
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Maria Carolina Ballarino
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Alberto Chervin
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Karina Danilowicz
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sabrina Diez
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Patricia Fainstein Day
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Natalia García-Basavilbaso
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariela Glerean
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mirtha Guitelman
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Débora Katz
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Monica Graciela Loto
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marcela Martinez
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Karina Miragaya
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Moncet
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Amelia Susana Rogozinski
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marisa Servidio
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Graciela Stalldecker
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marcelo Vitale
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Boero
- Departamento de Neuroendocrinología (Neuroendocrinology Department), Sociedad Argentina de Endocrinología y Metabolismo, Ciudad Autónoma de Buenos Aires, Argentina
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Auriemma RS, Grasso LFS, Pivonello R, Colao A. The safety of treatments for prolactinomas. Expert Opin Drug Saf 2016; 15:503-12. [DOI: 10.1517/14740338.2016.1151493] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Renata S. Auriemma
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Ludovica F. S. Grasso
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, University ‘Federico II’, Naples, Italy
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Iacovazzo D, De Marinis L. Treatment of hyperprolactinemia in post-menopausal women: pros. Endocrine 2015; 48:76-8. [PMID: 25112228 DOI: 10.1007/s12020-014-0377-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
The incidence of hyperprolactinemia in women peaks during the 3rd-4th decade and then greatly decreases after the menopause. Apart from the effects on the hypothalamic-pituitary-gonadal axis, prolactin can act directly on bone metabolism. Hyperprolactinemia is a recognized cause of secondary osteoporosis, and treatment with dopamine agonists can lead to improved BMD. Moreover, hyperprolactinemia has been linked to weight gain and insulin resistance, which can be ameliorated following medical treatment. Although relatively rare, prolactinomas can be observed in post-menopausal women and are frequently large and invasive; dopamine agonists appear to be as effective in these patients as in younger women to induce reduction of prolactin levels and tumour shrinkage. Here, we review data potentially favouring medical treatment with dopamine agonists in post-menopausal women diagnosed with hyperprolactinemia.
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Affiliation(s)
- D Iacovazzo
- Endocrinology, Università Cattolica del Sacro Cuore, Policlinico "A. Gemelli", Rome, Italy,
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Faje AT, Klibanski A. The treatment of hyperprolactinemia in postmenopausal women with prolactin-secreting microadenomas: cons. Endocrine 2015; 48:79-82. [PMID: 24888765 DOI: 10.1007/s12020-014-0308-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Alexander T Faje
- BUL 457, Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
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Abstract
Prolactinomas are the most frequent pituitary adenomas. In patients with prolactinomas the primary cause of hyperprolactinemia is excessive and autonomic production of prolactin by lactotroph cells. In other conditions, except in case of macroprolactinemia, hyperprolactinemia is secondary to circumstances that stimulate secretion of prolactin by intrinsically normal lactotroph cells, or, rarely, that are the result of decreased clearance of prolactin. In general, cabergoline is the preferred treatment for micro- and macroprolactinomas, because it is more effective with respect to normalization of prolactin levels and reduction of prolactinoma size and because it has fewer side-effects compared to bromocriptine. Recently, it has been suggested that a standardized, individualized, stepwise, dose-escalating regimen of cabergoline may normalize prolactin levels and reduce prolactinoma size in patients who were otherwise considered to be dopamine agonist resistant. In general, the cardiac adverse effects of dopamine agonists reported in Parkinson's disease are not of clinical concern in the treatment of prolactinomas, which are treated with much lower doses. Nonetheless, there is uncertainty with respect to the dose and duration of cabergoline treatment, which requires echocardiographic follow-up. Although withdrawal of dopamine agonists may be considered in patients with prolactinomas well controlled by dopamine agonists, especially in postmenopausal women, recurrence of signs and symptoms may occur in a considerable portion of patients.
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Affiliation(s)
- Johannes A Romijn
- Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Halperin Rabinovich I, Cámara Gómez R, García Mouriz M, Ollero García-Agulló D. [Clinical guidelines for diagnosis and treatment of prolactinoma and hyperprolactinemia]. ACTA ACUST UNITED AC 2013; 60:308-19. [PMID: 23477758 DOI: 10.1016/j.endonu.2012.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To provide practical and up to date recommendations for evaluation, differential diagnosis, and treatment of prolactinoma and hyperprolactinemia in various clinical settings. PARTICIPANTS Members of the Neuroendocrinology Working Group of the Spanish Society of Endocrinology. METHODS Recommendations were formulated according to the Grading of Recommendations, Assessment, Development, and Evaluation system (GRADE) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in Medline (Pubmed) for each subject, and authors' considerations were added in areas where the literature provided scarce evidence. Finally, recommendations were jointly discussed by the Working Group. CONCLUSIONS The document provides evidence-based practical and updated recommendations for diagnosis and management of hyperprolactinemia and prolactinoma, including drug-induced hyperprolactinemia, treatment options for prolactinoma (drugs, surgery, and radiotherapy), prolactinoma in pregnancy, adverse effects of dopaminergic agents, and drug-resistant and malignant prolactinomas.
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Affiliation(s)
- Irene Halperin Rabinovich
- Servicio de Endocrinología y Nutrición, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
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Wang AT, Mullan RJ, Lane MA, Hazem A, Prasad C, Gathaiya NW, Fernández-Balsells MM, Bagatto A, Coto-Yglesias F, Carey J, Elraiyah TA, Erwin PJ, Gandhi GY, Montori VM, Murad MH. Treatment of hyperprolactinemia: a systematic review and meta-analysis. Syst Rev 2012; 1:33. [PMID: 22828169 PMCID: PMC3483691 DOI: 10.1186/2046-4053-1-33] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 07/24/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hyperprolactinemia is a common endocrine disorder that can be associated with significant morbidity. We conducted a systematic review and meta-analyses of outcomes of hyperprolactinemic patients, including microadenomas and macroadenomas, to provide evidence-based recommendations for practitioners. Through this review, we aimed to compare efficacy and adverse effects of medications, surgery and radiotherapy in the treatment of hyperprolactinemia. METHODS We searched electronic databases, reviewed bibliographies of included articles, and contacted experts in the field. Eligible studies provided longitudinal follow-up of patients with hyperprolactinemia and evaluated outcomes of interest. We collected descriptive, quality and outcome data (tumor growth, visual field defects, infertility, sexual dysfunction, amenorrhea/oligomenorrhea and prolactin levels). RESULTS After review, 8 randomized and 178 nonrandomized studies (over 3,000 patients) met inclusion criteria. Compared to no treatment, dopamine agonists significantly reduced prolactin level (weighted mean difference, -45; 95% confidence interval, -77 to -11) and the likelihood of persistent hyperprolactinemia (relative risk, 0.90; 95% confidence interval, 0.81 to 0.99). Cabergoline was more effective than bromocriptine in reducing persistent hyperprolactinemia, amenorrhea/oligomenorrhea, and galactorrhea. A large body of noncomparative literature showed dopamine agonists improved other patient-important outcomes. Low-to-moderate quality evidence supports improved outcomes with surgery and radiotherapy compared to no treatment in patients who were resistant to or intolerant of dopamine agonists. CONCLUSION Our results provide evidence to support the use of dopamine agonists in reducing prolactin levels and persistent hyperprolactinemia, with cabergoline proving more efficacious than bromocriptine. Radiotherapy and surgery are useful in patients with resistance or intolerance to dopamine agonists.
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Affiliation(s)
- Amy T Wang
- Knowledge and Evaluation Research Unit and Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Abstract
PURPOSE OF REVIEW Despite the widespread use of dopamine agonists for patients with prolactinomas and symptomatic idiopathic hyperprolactinemia for many decades, the optimal treatment strategy and duration of treatment is still not evident. This review highlights the effects of dopamine agonist withdrawal in patients with idiopathic hyperprolactinemia and prolactinomas in detail, including the factors influencing the success of treatment outcome. RECENT FINDINGS It appeared that a subgroup of patients with a high likelihood of achieving remission could be identified on clinical criteria, which were incorporated in the Pituitary Society 2006 consensus guidelines. A recent systematic review and meta-analysis, however, demonstrated that the pooled proportion of patients with persisting normoprolactinemia after dopamine agonist withdrawal was only 21%, with a higher treatment success in idiopathic hyperprolactinemia (32%), compared with both microprolactinomas (21%) and macroprolactinomas (16%). In a random effects meta-regression, longer treatment duration was associated with treatment success. The probability of treatment success was highest when cabergoline was used for at least 2 years. Recommendations have now been adjusted accordingly in the 2011 Endocrine Society Practical guideline. SUMMARY Hyperprolactinemia will recur after dopamine agonist withdrawal in a considerable proportion of patients, but not all dopamine agonists have comparable efficacy. The optimal withdrawal strategy still needs to be determined in further studies.
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Affiliation(s)
- Alberto M Pereira
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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29
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Abstract
Prolactinomas, the most prevalent type of neuroendocrine disease, account for approximately 40% of all pituitary adenomas. The most important clinical problems associated with prolactinomas are hypogonadism, infertility and hyposexuality. In patients with macroprolactinomas, mass effects, including visual field defects, headaches and neurological disturbances, can also occur. The objectives of therapy are normalization of prolactin levels, to restore eugonadism, and reduction of tumor mass, both of which can be achieved in the majority of patients by treatment with dopamine agonists. Given their association with minimal morbidity, these drugs currently represent the mainstay of treatment for prolactinomas. Novel data indicate that these agents can be successfully withdrawn in a subset of patients after normalization of prolactin levels and tumor disappearance, which suggests the possibility that medical therapy may not be required throughout life. Nevertheless, multimodal therapy that involves surgery, radiotherapy or both may be necessary in some cases, such as patients who are resistant to the effects of dopamine agonists or for those with atypical prolactinomas. This Review reports on efficacy and safety of pharmacotherapy in patients with prolactinomas.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, University Federico II of Naples, Italy, Via Sergio Pansini 5, I-80131 Naples, Italy.
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Abstract
BACKGROUND Prolactinomas are the most common hormone-secreting pituitary tumours and are amenable to medical therapy with dopamine agonists. Indication for treatment will most commonly result from hypogonadism, infertility or symptoms related to tumour size. Thus, both diagnosis and treatment will essentially depend on the patients' stage of life, namely prepubertal, reproductive or postreproductive stage. This review will focus on a lifespan-dependent diagnosis and treatment for prolactinoma and hyperprolactinaemia. METHODS PubMed, the Cochrane Library, the Web of Science and EMBASE were searched electronically. No restriction was made with respect to language. Relevant current articles will be included in this review. RESULTS Prevalence of prolactinomas and clinical symptoms are age group-specific, and treatment of first choice is dopamine agonists over the whole lifespan. Open questions in the treatment for hyperprolactinaemia include optimal choice and duration of pharmacological treatment. In addition, concerns have been raised on the safety of dopamine agonists since a reported association of valvular heart disease with dopaminergic treatment in patients with Parkinson's disease. CONCLUSIONS Clinical presentation and consequences of hyperprolactinaemia and prolactinoma will differ in the specific stages of reproductive life and require an adequate lifetime-dependent diagnostic and therapeutic approach.
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Affiliation(s)
- W Alexander Mann
- Endokrinologikum Frankfurt, Academic Teaching Unit of Goethe University Frankfurt, Frankfurt am Main, Germany.
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Ogilvie CM, Milsom SR. Dopamine agonists in the treatment of prolactinoma: are they still first choice? Intern Med J 2011; 41:156-61. [DOI: 10.1111/j.1445-5994.2010.02410.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital, and Harvard Medical School, Boston, MA 02114, USA.
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Abstract
This review focus on the epidemiology, diagnosis and treatment of prolactinomas. In particular, attention was given to recent data showing a high prevalence of these tumours in the general population, 3-5 times higher than previously reported. The diagnosis of hyperprolactinaemia has been simplified in recent years, and only prolactin (PRL) assay and magnetic resonance imaging of the sella are required. Nonetheless, macroprolactinaemia should be assessed in patients with hyperprolactinaemia in the absence of clinical symptoms of elevated PRL levels. The recent evidence that medical therapy with dopamine agonists should be continued lifelong has been confirmed by several studied. The patients achieving disappearance of the tumours and suppression of PRL levels during treatment are those showing the highest likelihood to have persistent remission of hyperprolactinaemia after treatment withdrawal.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Federico II University, via S. Pansini 5, 80131 Naples, Italy.
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Abstract
According to epidemiological studies, the prevalence of pituitary adenomas is 16.5% and the majority of them are "incidentalomas". The symptoms of pituitary disorders are often non-specific; disturbances of pituitary function, compression symptoms, hypophysis apoplexy or accidental findings may help the diagnosis. The hormonal evaluation of pituitary adenomas is different from the algorithm used in the disorders of peripheral endocrine organs. The first-line therapy of prolactinomas are the dopamine agonists, and the aims of the treatment are to normalize the prolactin level, restore fertility in child-bearing age, decrease tumor mass, save or improve the residual pituitary function and inhibit the relapse of the disease. The available dopamine agonists in Hungary are bromocriptine and quinagolide. In case of tumors with good therapeutic response, medical therapy can be withdrawn after 3-5 years; hyperprolactinemia will not recur in 2/3 of these patients. Neurosurgery is the primary therapy of GH-, ACTH-, TSH-producing and inactive adenomas. In the last decades, significant improvement has been reached in surgical procedures, resulting in low mortality rates. Acromegalic patients with unresectable tumors have a great benefit from somatostatin analog treatment. The growth hormone receptor antagonist pegvisomant is the newest modality for the treatment of acromegaly. The medical therapy of Cushing's disease is still based on the inhibition of steroid production. A new, promising somatostatin analog, pasireotide is evaluated in clinical trials. The rare TSH-producing tumor can respond to both dopamine agonist and somatostatin analog therapy. The application of conventional radiotherapy has decreased; radiotherapy is mainly used in the treatment of invasive, incurable or malignant tumors. Further studies are needed to elucidate the exact role of radiosurgery and fractionated stereotaxic irradiation in the treatment of pituitary tumors.
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Affiliation(s)
- Emese Mezosi
- Pécsi Tudományegyetem, Klinikai Központ I. Belgyógyászati Klinika Pécs.
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Abstract
Hyperprolactinaemia is a common condition with varied aetiology. It is more frequent in women, but also seen in men and even in adolescence and childhood. Prolactin is mainly a lactogenic hormone but has other actions. Most cases present with amenorrhoea and infertility and are managed by gynaecologists. However, multidisciplinary involvement may be required in some cases. Evidence relating to aetiology, clinical features, pathogenesis and management has been discussed.
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Kharlip J, Salvatori R, Yenokyan G, Wand GS. Recurrence of hyperprolactinemia after withdrawal of long-term cabergoline therapy. J Clin Endocrinol Metab 2009; 94:2428-36. [PMID: 19336508 PMCID: PMC2708963 DOI: 10.1210/jc.2008-2103] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Recurrence of hyperprolactinemia after cabergoline withdrawal ranges widely from 36 to 80%. The Pituitary Society recommends withdrawal of cabergoline in selected patients. OBJECTIVE Our aim was to evaluate recurrence of hyperprolactinemia in patients meeting The Pituitary Society guidelines. DESIGN Patients were followed from the date of discontinuation to either relapse of hyperprolactinemia or the day of last prolactin test. SETTING We conducted the study at an academic medical center. PATIENTS Forty-six patients meeting Pituitary Society criteria (normoprolactinemic and with tumor volume reduction after 2 or more years of treatment) participated in the study. INTERVENTIONS After withdrawal, if prolactin returned above reference range, another measurement was obtained within 1 month, symptoms were assessed by questionnaire, and magnetic resonance imaging was performed. MAIN OUTCOME MEASURES We measured risk of and time to recurrence estimates as well as clinical predictors of recurrence. RESULTS Mean age of patients was 50 +/- 13 yr, and 70% were women. Thirty-one patients had microprolactinomas, 11 had macroprolactinomas, and four had nontumoral hyperprolactinemia. The overall recurrence was 54%, and the estimated risk of recurrence by 18 months was 63%. The median time to recurrence was 3 months (range, 1-18 months), with 91% of recurrences occurring within 1 yr after discontinuation. Size of tumor remnant prior to withdrawal predicted recurrence [18% increase in risk for each millimeter (95% confidence interval, 3-35; P = 0.017)]. None of the tumors enlarged in the patients experiencing recurrence, and 28% had symptoms of hypogonadism. CONCLUSIONS Cabergoline withdrawal is practical and safe in a subset of patients as defined by The Pituitary Society guidelines; however, the average risk of long-term recurrence in our study was over 60%. Close follow-up remains important, especially within the first year.
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Affiliation(s)
- J Kharlip
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland 21201, USA.
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37
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Bronstein MD. Long-term control of macroprolactinomas. Expert Rev Endocrinol Metab 2008; 3:361-376. [PMID: 30754204 DOI: 10.1586/17446651.3.3.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyperprolactinemia is the most prevalent hypothalamic-pituitary dysfunction, with prolactinomas being its main cause. Microprolactinomas (diameter < 10 mm) represent approximately 60% of the prolactin-secreting adenomas, and are far more common in women than in men, whereas macroadenomas have roughly the same prevalence in both genders. The treatment of patients harboring macroprolactinomas is highly gratifying, with more than 80% of them adequately controlled by dopamine-agonist (DA) drugs: cabergoline being the most efficacious to date. Emerging evidence points to remission of the disease after long-term DA therapy in a significant number of patients. The remaining cases, mainly those with enclosed tumors, may be treated successfully by pituitary surgery. Radiotherapy is reserved for cases with dopaminergic drug resistance not surgically cured. The development of new therapeutic approaches may turn the control of the subset of macroprolactinomas refractory to both DA and surgery into reality.
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Affiliation(s)
- Marcello D Bronstein
- a Professor of Endocrinology, Chief, Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar 155-Predio dos Ambulatorios-8o andar-bloco3. CEP: 05403-900, Sao Paulo, SP, Brazil.
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38
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Abstract
Hyperprolactinaemia is a frequent cause of reproductive problems encountered in clinical practice. A variety of pathophysiological conditions can lead to hyperprolactinaemia; therefore, pregnancy, drug effects, hypothyroidism and polycystic ovary syndrome should be excluded before investigating for prolactin-secreting pituitary tumours. Prolactinomas are mainly diagnosed in women aged 20-40 years. They present with clinical features of hyperprolactinaemia (galactorrhoea, gonadal dysfunction), and more rarely with large tumours, headache and visual field loss due to optic chiasm compression. Medical therapy with dopamine agonists is the treatment of choice for both micro- and macroprolactinomas. Tumour shrinkage and restoration of gonadal function are achieved in the majority of cases with dopamine agonists. A trial of withdrawal of medical therapy may be considered in many patients with close follow-up. Pituitary surgery and radiotherapy currently have very limited indications. Pregnancies in patients with prolactinomas need careful planning and close monitoring.
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Affiliation(s)
- V K B Prabhakar
- Department of Endocrinology, Manchester Royal Infirmary, Manchester M13 9WL, UK
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Abstract
Any process interfering with dopamine synthesis, its transport to the pituitary gland, or its action at the level of lactotroph dopamine receptors can cause hyperprolactinemia. As described in this article, considering the complexity of prolactin regulation, many factors could cause hyperprolactinemia, and hyperprolactinemia can have clinical effects not only on the reproductive axis. Once any drug effects are excluded, prolactinomas are the most common cause of hyperprolactinemia. The most frequent symptom is hypogonadism in both genders. Medical and surgical therapies generally have excellent results, and most prolactinomas are well controlled or even cured in some cases.
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Affiliation(s)
- Tatiana Mancini
- Internal Medicine, San Marino Hospital, 47899, Republic of San Marino
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40
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Abstract
OBJECTIVE Stresses including surgery, exercise, nipple stimulation, and chest wall injury such as mechanical trauma, burns, surgery, herpes zoster of thoracic dermatomes, hypoglycaemia and acute myocardial infarction cause significant elevation of prolactin levels. The aim of the present study was to evaluate the changes in prolactin level during mammography and ultrasonographic examination. MATERIALS AND METHODS Seventy-four premenopausal (mean age, 32.1+/-7.3 y) and 81 post-menopausal women (mean age, 48.3+/-8.9 y) were enrolled into the study. Premenopausal women were evaluated with ultrasound (Senographe 600 T [General Electric]) and post-menopausal women were examined with mammography (Mammomat 3000 [Siemens]). Blood samples for prolactin were taken prior to ultrasound or mammography and 15, 30 and 45 min after ultrasound or mammography. RESULTS Mean baseline serum prolactin level was 7.2+/-0.9 ng/ml in premenopausal women before ultrasound. Mean baseline serum prolactin level was 5.4+/-0.4 ng/ml in post-menopausal women before mammography. It was found that there were no significant changes in prolactin levels after ultrasound or mammography (P > 0.05). Mean levels of baseline prolactin were statistically significant higher in premenopausal than in post-menopausal women (P = 0.03). CONCLUSION Mammography and ultrasonographic examination have no acute effect on serum prolactin levels in either group. There is no need to wait before measuring the prolactin level after mammographic or ultrasonographic breast examination.
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Abstract
In several respects prolactin is unique among anterior pituitary hormones. The primary regulation of prolactin secretion is mediated through hypothalamic inhibition, and the diagnosis of hyperprolactinemia can be established without the use of stimulation or suppression tests. Documenting the presence of hyperprolactinemia is not difficult-the challenge is in identifying the cause of the hormone hypersecretion. With immunoradiometric assays falsely low levels of prolactin are occasionally seen in patients with macroadenomas and very high serum prolactin (the hook effect). Macroprolactin should be suspected when a patient with hyperprolactinemia does not present with typical clinical symptoms, and all hyperprolactinemic sera should be screened for macroprolactin. With prolactinomas, prolactin levels generally parallel tumor size. Prolactin secreting macroadenomas are typically associated with levels that exceed 250 microg/l and may exceed 1,000 microg/l. Large non-functioning adenomas also lead to hyperprolactinemia but levels virtually never exceed 94 microg/l. Acquired and isolated prolactin deficiency is rare.
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Affiliation(s)
- Jaspreet Chahal
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
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43
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Colao A, Di Sarno A, Guerra E, Pivonello R, Cappabianca P, Caranci F, Elefante A, Cavallo LM, Briganti F, Cirillo S, Lombardi G. Predictors of remission of hyperprolactinaemia after long-term withdrawal of cabergoline therapy. Clin Endocrinol (Oxf) 2007; 67:426-33. [PMID: 17573902 DOI: 10.1111/j.1365-2265.2007.02905.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Remission rates of 76, 69.5 and 64.3% have been reported in patients with nontumoural hyperprolactinaemia (NTH), microprolactinoma and macroprolactinoma, respectively, 2-5 years after cabergoline (CAB) withdrawal. OBJECTIVE To report the estimated recurrence rate at 24-96 months after CAB withdrawal and indicate predictors of disease remission. DESIGN Observational, analytical, prospective. PATIENTS Of 381 previously untreated de novo patients with hyperprolactinaemia, 221 (58%) (173 women, 48 men; 27 with NTH, 115 with micro-, and 79 with macroprolactinoma) were studied. MEASUREMENTS Using multiple regression analysis the diagnostic accuracy of nadir PRL levels (t = 7.6, P < 0.0001) and nadir maximal tumour diameter at CAB withdrawal (t = 3.9, P < 0.001) was analysed using receiver operating characteristic (ROC) curves. RESULTS The recurrence of hyperprolactinaemia was 25.9, 33.9 and 53.1% in patients with NTH, micro- or macroprolactinoma, respectively. To predict the last PRL level after withdrawal, the optimum cut-off of nadir PRL levels at withdrawal was 162 mU/l (5.4 microg/l) [sensitivity (95% CI) 76% (67-84%), specificity 65% (51-77%)] and that of nadir maximal tumour diameter was 3.1 mm [sensitivity 52% (41-63%), specificity 86% (79-91%)]. The patients achieving both nadir PRL levels </= 162 mU/l and maximal tumour diameter </= 3.1 mm (n = 111) at CAB withdrawal had a significantly lower Kaplan-Meier estimate of recurrence of hyperprolactinaemia (20%) at 24-96 months than those who did not fulfil any of these criteria [(n = 38) 90%; P < 0.0001]. Patients achieving nadir PRL levels </= 162 mU/l (n = 26) or maximal tumour diameter </= 3.1 mm during CAB treatment (n = 46) had an estimated recurrence rate of hyperprolactinaemia of 50 and 56%, respectively. CONCLUSION Persistent remission of hyperprolactinaemia without any evidence of tumour re-growth after 24-96 months of CAB withdrawal occurred in the majority of patients with NTH and microprolactinoma and in about half of those with macroprolactinoma. Nadir PRL levels and maximal tumour diameter at CAB withdrawal of </= 162 mU/l and </= 3.1 mm predicted remission of hyperprolactinaemia in 80% of patients.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Section of Endocrinology, University 'Federico II' of Naples, Naples, Italy.
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44
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Abstract
Prolactinomas are a frequent cause of gonadal dysfunction and infertility, especially in young women. The regulation of prolactin secretion and the efficacy of dopamine agonists in the therapy of prolactinomas are well established. The current challenges in management of prolactinomas are related to follow-up after successful therapy. Issues and questions to be addressed in this approach to long-term management of prolactinomas include the frequency of radiographic monitoring, effect of pregnancy and menopause, safety of estrogen in women taking oral contraceptives, and the potential for discontinuation of dopamine agonist therapy.
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Affiliation(s)
- Janet A Schlechte
- Department of Internal Medicine, 157 MRF, University of Iowa Hospital, 200 Hawkins Drive, Iowa City, Iowa 52242, USA.
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45
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Chanson P, Borson-Chazot F, Chabre O, Estour B. Drug treatment of hyperprolactinemia. ANNALES D'ENDOCRINOLOGIE 2007; 68:113-7. [PMID: 17532288 DOI: 10.1016/j.ando.2007.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Accepted: 03/12/2007] [Indexed: 11/18/2022]
Abstract
Medical treatment of hyperprolactinemia is based upon use of dopamine agonists (DA): bromocriptine, lisuride, quinagolide and cabergoline. In over 80% of cases, these drugs induce normal prolactinemia and ovulatory cycles. In resistant cases, the DA should be changed. Tolerance may occasionally be poor, particularly with bromocriptine, which appears less well-tolerated than quinagolide and than cabergoline above all. In the event of intolerance to a given DA, another should be tried. In patients with macroprolactinoma treated with DA, MRI monitoring should be carried out after 3 months of treatment to verify tumor size reduction, then after 1 year, yearly for the next 5 years and once every 5 years if adenoma size is stable. In cases of microprolactinoma, control under treatment is pointless. MRI may be performed after 1 year and then after 5 years. Once normal prolactin levels have been achieved, attempts may be made to stop the treatment. When a prolonged treatment is interrupted, especially with cabergoline, progressive increase in serum prolactin and return of hyperprolactinemia symptoms are seen in only around 20-30% of cases, particularly when residual adenoma exists after prolonged treatment. Nevertheless, prolactin levels should continue to be monitored after discontinuation of DA, possibly with MRI monitoring, since prolactin levels may rise again after a number of months or years. When normal prolactin levels have been achieved with DA, another solution consists in reducing the dose or dosing frequency of DA in steps to the lowest effective dose consistent with maintenance of normal prolactin levels and stable adenoma size. For drug-induced hyperprolactinemia, where the causative medication cannot be withdrawn, it is often pointless and possibly even dangerous to administer a DA. It is therefore necessary to check for absence of pituitary adenoma and where necessary, begin treatment with sex steroids so as to ensure satisfactory impregnation with sex steroids and avoid osteoporosis. For macroprolactinoma, the first-line treatment is drug therapy with DA. At present, there is no evidence to suggest that prior treatment with DA can modify the outcome of surgery. With microprolactinoma, DA treatment offers a good first-line therapeutic option but surgery may also be useful. DAs for microprolactinoma may be withdrawn after menopause.
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Affiliation(s)
- P Chanson
- Service d'endocrinologie et des maladies de la reproduction, hôpital de Bicêtre, 78, rue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
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46
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Brue T, Delemer B. Diagnosis and management of hyperprolactinemia: expert consensus - French Society of Endocrinology. ANNALES D'ENDOCRINOLOGIE 2007; 68:58-64. [PMID: 17316545 DOI: 10.1016/j.ando.2006.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Accepted: 11/30/2006] [Indexed: 10/22/2022]
Affiliation(s)
- T Brue
- Service d'endocrinologie, hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France.
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47
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Neff LM, Weil M, Cole A, Hedges TR, Shucart W, Lawrence D, Zhu JJ, Tischler AS, Lechan RM. Temozolomide in the treatment of an invasive prolactinoma resistant to dopamine agonists. Pituitary 2007; 10:81-6. [PMID: 17285366 DOI: 10.1007/s11102-007-0014-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Prolactinomas are common tumors of the anterior pituitary gland. While conventional therapies, including dopamine agonists, transsphenoidal surgery and radiotherapy, are usually effective in controlling tumor growth, some patients develop treatment-resistant tumors. In this report, we describe a patient with an invasive prolactinoma resistant to conventional therapy that responded to the administration of the alkylating agent, temozolomide.
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Affiliation(s)
- Lisa M Neff
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Tufts-New England Medical Center, Boston, MA 02111, USA
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48
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Tomei F, Ciarrocca M, Cherubini E, Rosati MV, Monti C, Capozzella A, Tomei G. Prolactin Levels in Workers Exposed to Chemical, Physical and Psycho‐Social Urban Stressors. J Occup Health 2006; 48:253-60. [PMID: 16902269 DOI: 10.1539/joh.48.253] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to evaluate whether traffic police officers exposed to chemical, physical and psycho-social stressors, are at risk for alterations in plasma levels of prolactin (PRL) compared to a control group. Plasma PRL levels were evaluated in 92 male and 51 female, non-smoker, traffic police officers exposed to urban stressors and in 92 male and 51 female controls, matched by sex, age and working life (mean, SD and distribution), after excluding workers with the principal extra-occupational confounding factors. Mean PRL levels were significantly higher than controls in non-smoker, male and female traffic police officers (respectively, p=0.000 and p=0.013). The number of non-smoker, male and female traffic police officers with PRL values outside the upper normal limit for our laboratory was higher than, but not significantly different from controls. Mean PRL levels were not significantly higher than controls in smoker, male and female traffic police officers. The number of smoker, male and female traffic police officers with PRL values outside the normal limit for our laboratory was not significantly different from controls. The results suggest that exposure to urban chemical and physical stressors, interacting with psychosocial factors, may have an influence on PRL levels in traffic police officers. The level of plasma PRL might be a useful early biological marker for workers exposed to urban stressors.
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Affiliation(s)
- Francesco Tomei
- Department of Occupational Medicine, University of Rome "La Sapienza".
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49
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Abstract
Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.
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Affiliation(s)
- Mary P Gillam
- Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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50
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Casanueva FF, Molitch ME, Schlechte JA, Abs R, Bonert V, Bronstein MD, Brue T, Cappabianca P, Colao A, Fahlbusch R, Fideleff H, Hadani M, Kelly P, Kleinberg D, Laws E, Marek J, Scanlon M, Sobrinho LG, Wass JAH, Giustina A. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol (Oxf) 2006; 65:265-73. [PMID: 16886971 DOI: 10.1111/j.1365-2265.2006.02562.x] [Citation(s) in RCA: 453] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In June 2005, an ad hoc Expert Committee formed by the Pituitary Society convened during the 9th International Pituitary Congress in San Diego, California. Members of this committee consisted of invited international experts in the field, and included endocrinologists and neurosurgeons with recognized expertise in the management of prolactinomas. Discussions were held that included all interested participants to the Congress and resulted in formulation of these guidelines, which represent the current recommendations on the diagnosis and management of prolactinomas based upon comprehensive analysis and synthesis of all available data.
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Affiliation(s)
- Felipe F Casanueva
- Department of Medicine, Endocrine Division, Santiago de Compostela University, Spain.
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