Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:19

1220 Prolactinoma and Galactorrhea

■Ancillary blood tests:

➣LH, FSH

➣Testosterone

➣Estradiol

➣DHEA-S

Imaging

■MRI of pituitary to determine if microadenoma (<1 cm), macroade-

noma (>1 cm), or hypothalamic mass present

differential diagnosis

■Hyperprolactinemia without pituitary mass

■Primary hypothyroidism

■Pregnancy and breastfeeding cause physiologic hyperprolactinemia

■Nonsecretory pituitary macroadenoma; stalk compression leads to

decreased dopamine transmission to pituitary and hyperprolactine-

mia

■Acromegaly; tumor may secrete both GH and Prolactin

■May be associated with polycystic ovarian disease

■Idiopathic galactorrhea with normal prolactin levels

Nipple stimulation may raise prolactin level (rare)

management

What to Do First

■Rule out pregnancy and primary hypothyroidism

■Determine presence or absence of pituitary mass by MRI:

➣Macroadenoma, prolactin <100–150 ng/dL: nonsecretory pitu-

itary mass

➣Macroadenoma, prolactin >150 ng/dL: macroprolactinoma

➣Microadenoma: microprolactinoma (may be incidental pituitary

adenoma, esp if <4 mm); most commonly seen in women

➣No mass: idiopathic hyperprolactinemia

specific therapy

■Nonsecretory macroadenoma:

➣Surgery to debulk tumor if visual field cut or headache

➣Observation with repeated pituitary MRI to determine if tumor

growing

➣Radiation therapy (eg, gamma knife) if tumor grows

➣Dopaminergic agents (bromocriptine or cabergoline) to

decrease prolactin levels and decrease galactorrhea