An observational study of pregnancy and post-partum outcomes in women with prolactinoma treated with dopamine agonists

Does hyperprolactinemia treatment affect pregnancy and perinatal outcomes?

OBJECTIVE

The aim of this study was to assess obstetric and perinatal outcomes in women with hyperprolactinemia according to the type of treatment indicated, with cabergoline or bromocriptine.

METHODS

A retrospective cohort study with 464 women diagnosed with hyperprolactinemia was undertaken at the endocrine gynecology outpatient clinic of a tertiary hospital from May 2002 to February 2022. All women diagnosed with hyperprolactinemia who were being treated with dopamine agonists (cabergoline or bromocriptine) and who became pregnant during the follow-up were included. Women whose medical records did not provide data related to pregnancy and delivery were excluded. The women were divided into two groups according to the type of treatment: bromocriptine or cabergoline. Clinical and laboratory characteristics and obstetric and perinatal outcomes, such as complications during pregnancy, type of delivery, and intrapartum complications, were evaluated in both groups.

RESULTS

Of the 464 women evaluated, 72 became pregnant during the follow-up, 66 of them were using dopamine agonists, while 6 were not using medication. The mean age of the women was 28.3±6.8 years. Among the causes of hyperprolactinemia, 48.6% were idiopathic, 45.7% were tumoral, and 3.7% had other causes. Most women with idiopathic hyperprolactinemia used bromocriptine, while those with tumoral hyperprolactinemia used cabergoline (p=0.04). There was no difference in obstetric outcomes according to the type of treatment used. The majority of women did not have any complications during pregnancy (76.3%) or intrapartum (86.8%).

CONCLUSION

Regardless of the type of previous drug treatment with dopamine agonists, hyperprolactinemia does not alter obstetric outcomes.

Prolactinomas: Preconception and During Pregnancy

Prolactinomas are a common cause of infertility in women. Medical treatment with dopamine agonists (DAs) has an excellent efficacy at restoring fertility and a reassuring safety profile in early pregnancy. Surgical treatment before conception is required in some cases of large macroadenomas and incomplete treatment response. In women with microprolactinomas, the pregnancy course is usually uneventful. In women with macroprolactinomas that are near/abut the optic chiasm, symptomatic tumor enlargement can occur during pregnancy and require a multidisciplinary team approach. This review provides an update regarding outcomes and management of prolactinomas before conception, during pregnancy, and postpartum.

Prolactin-secreting tumors, dopamine agonists and pregnancy: a longitudinal experience of a tertiary neuroendocrine center

PURPOSE

Prolactin (PRL)-secreting tumours are associated with infertility and can be reverted by dopamine agonist (DA) therapy. The suspension of DA is recommended once pregnancy is established, as all DAs cross the placenta. The aim of the study was to evaluate the rate of maternal-foetal complications in women treated with cabergoline (CAB) or bromocriptine (BRM) for prolactinoma during gestation and the effect of pregnancy on prolactinoma progression.

METHODS

This was a retrospective observational study involving 43 women affected by prolactinoma who became pregnant during therapy with CAB or BRM for a total of 58 pregnancies. For each patient, medical records were analysed by integrating the data with outpatient or telephone interview.

RESULTS

At the time of conception, 18 women were in the BRM group, while 40 were in CAB group. No differences were found in obstetric or neonatal outcomes between the two groups. There was a significant difference (p = 0.046) in child complications reported in maternal interview found exclusively in the CAB group. No further confounding factors were detected. Disease remission rate after the first pregnancy was 42.9% and the main predictor was a lower PRL nadir before pregnancy (p = 0.023). No difference was detected between the two groups in terms of tumor remission. Breastfeeding did not modify the outcome.

CONCLUSION

Foetal exposure to DAs during the first weeks of embryogenesis is not associated with a greater risk of complications. The transient and mild developmental disorders recorded resolved spontaneously and the prevalence was substantially overlapping with that observed in the general population.

Approach to the Patient With Prolactinoma

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.

Cabergoline Failure and a Spontaneous Pregnancy in a Microprolactinoma with High Prolactin Levels

We report a particular case of a spontaneously occurring pregnancy in a long-term amenorrheic patient due to a prolactinoma with high serum prolactin (PRL) following the failure of dopamine agonist therapy (DA) for infertility. Initially, clinical, laboratory, and genital ultrasounds were normal, but the serum PRL was 10,074 μIU/mL (n.v.: 127−637 μIU/mL), the PEG fraction was 71% (laboratory cut-off > 60%), and luteinizing hormone (LH) was significantly lower. An MRI revealed a pituitary tumor of 12.8/10 mm with a subacute intratumoral hemorrhage. DA was initiated, and menstrual bleeding reappeared with a reduction in the tumor’s volume to 1.9/2.2 mm at 12 months. Two years later, the patient renounced DA and follow-ups. After another 2 years, she became spontaneously pregnant. Serum PRL was 18,325 μIU/mL, and an MRI revealed a microprolactinoma of 2.1/2 mm. The patient gave birth to a normal baby at term, and she breastfed for six months, after which she asked for ablactation, and DA was administered. This case highlights the possibility of the occurrence of a normal pregnancy during a long period of amenorrhea induced by a microprolactinoma with a high level of serum PRL, even if DA fails to correct infertility. There was no compulsory relationship between the tumoral volume’s evolution and the evolution of its lactophore activity. The hypogonadotrophic hypogonadism induced by high PRL was mainly manifested by low LH, and in this situation, normal levels of FSH and estradiol do not always induce follicle recruitment and development without abnormalities in the ovary ultrasound.

Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors

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.

Prolactinoma Outcome After Pregnancy and Lactation: A Cohort Study

CONTEXT

Prolactinoma is the most frequent pituitary tumor among women of childbearing age. Fewer studies have addressed the outcome of prolactinomas after gestation.

OBJECTIVE

The aim was to study the spontaneous remission rate and change in tumor size after pregnancy and/or lactation in women with prolactinomas.

PATIENTS AND METHODS

Retrospective study conducted at a tertiary care center of north India. Records of 25 women with 31 pregnancies (20 microprolactinomas and 11 macroprolactinomas), who conceived on dopamine agonist (cabergoline) were studied. Cabergoline was stopped at conception in 24 pregnancies and continued in 7. Serum prolactin was noted 3 months after delivery and/or lactation. Magnetic resonance imaging available at last visit after delivery and/or lactation was also noted. Remission was defined as normal serum prolactin after pregnancy and/or lactation without use of cabergoline.

RESULTS

Among patients in whom cabergoline was stopped during pregnancy (n = 24), 41.6% (n = 10) had prolactin in normal range (achieved remission) after pregnancy and/or lactation. In 25% (n = 6) of women, adenoma size decreased by more than 50%, in 33%(n = 8), there was no change in adenoma size, and in 42% (n = 10), decrease in adenoma size was less than 50% after pregnancy and/or lactation. The median duration of cabergoline treatment before pregnancy among patients who achieved remission was 60 months against 24 months in those who did not achieve remission. The median pre-pregnancy adenoma size was 5.5 mm in women with remission against 8 mm in women who did not achieve remission.

CONCLUSION

Pregnancy-induced remission of hyperprolactinemia was seen in 41.6% prolactinomas. Longer duration of dopamine agonist treatment before pregnancy, small pre-pregnancy adenoma size, and lower baseline prolactin were associated with high likelihood of remission, though not statistically significant.

Hyperprolactinemia after menopause: Diagnosis and management

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.

Outcomes of Patients with Macroprolactinoma Desiring Pregnancy: Follow-Up to 23 Years from a Single Center

Macroprolactinomas are rarely seen in women, and pregnancy is a risk factor for tumor growth. More studies are needed to determine appropriate management for macroprolactinoma and pregnancy. The aim of our study is to evaluate effects of treatment with dopamine agonists on macroadenoma before and during pregnancy, safety of dopamine agonists on fetus, post-pregnancy prognosis and long-term results. This is a single center retrospective study. Thirty-four pregnancies occurred in 21 patients under medical therapy. Prolactin levels, treatment results, tumor diameter changes, maternal-fetal outcomes, and disease activity were evaluated. The median tumor size at the time of diagnosis was 15 mm (10-28). Residual adenoma diameter was smaller in those receiving medical therapy longer than one year till the conception (p=0.047). Treatment was discontinued in 28 pregnancies after pregnancy confirmation, and 6 patients were exposed to bromocriptine throughout pregnancy. There was no symptomatic tumor growth during gestation. Among 27 live births, none of the fetuses developed neonatal malformation except for a case of Down syndrome. While early remission rate after pregnancy was 9.5%, this rate reached 33.3% at last follow-up visit. Lowered PRL levels at postpartum period (p=0.040), smaller tumor size at last follow-up visit (p=0.030), and total disappearance of tumor (p=0.026) were the contributor factors for remission. Use of dopamine agonist over one year may reduce the risk of symptomatic tumor growth during pregnancy in patients without invasive or large macroprolactinoma before pregnancy. Exposure to dopamine agonists seems generally safe for the fetus.