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pituitary adenoma/prolactin secreting (prolactinoma)

Epidemiology: - most common functional pituitary tumor Pathology: 1) women - almost always small tumors (microadenomas) - clinical course is benign - tumors rarely enlarge 2) men - generally large tumors (macroadenomas) - often aggressive tumors Genetics: - associated with defects in AIP Clinical manifestations: 1) women - oligomenorrhea - galactorrhea in 1/3 of patients - hirsuitism 2) men - erectile dysfunction - gynecomastia not necessarily present [1] - galactorrhea not necessarily present [1] 3) both sexes - infertility - decreased libido - headache - osteopenia Laboratory: - serum prolactin a) elevated with prolactinoma; > 200 ng/mL confirms diagnosis b) if < 200 ng/mL, also consider hypothyroidism Special laboratory: - formal visual field testing each trimester [1] Radiology: - MRI of pituitary (confirmation of diagnosis prior to treatment) [1] Differential diagnosis: - see hyperprolactinemia Complications: - prolactinomas may increase in size in pregnant women resulting in visual field loss [1] Management: 1) microprolactinomas in asymptomatic patients may be observed [1] 2) women a) dopaminergic agonist* - cabergoline preferred agent [1] - carbergoline 0.25 mg twice weekly - bromocryptine 5-10 mg PO QD - treat when fertility is the goal b) surgery - prolactinomas not responding to dopaminergic agonist [1] - most patients treated surgically relapse - overall surgical mortality is 1% - 50% of prolactinomas recur after resection [1] c) treat with birth control pills between pregnancies to ensure effective contraception, normal menses & skeletal integrity 3) men - bromocryptine* - cabergoline* [1] - trans-sphenoidal surgical resection - reserved for patients who fail bromocryptine - risk of morbidity & mortality * dopaminergic agonists decrease size of prolactinomas > 50% in 80-90% of patients [1] - initial management of prolactinoma with suprasellar extension & compression against the optic chiasm is dopamine agonist therapy [4]

Related

bromocriptine (Parlodel, Cycloset) prolactin in serum prolactin; lactogenic hormone (PRL)

General

pituitary adenoma

Database Correlations

OMIM correlations

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
  2. Klibanski A Clinical practice. Prolactinomas. N Engl J Med. 2010 Apr 1;362(13):1219-26 PMID: 20357284
  3. Mann WA Treatment for prolactinomas and hyperprolactinaemia: a lifetime approach. Eur J Clin Invest. 2011 Mar;41(3):334-42.
  4. NEJM Knowledge+
  5. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) web page "Prolactinoma" http://www.niddk.nih.gov/health/endo/pubs/prolact/prolact.htm