••• Chapter 59^ Disorders of Prolactin Secretion^595
❍ Is there a place for estrogen therapy in patients with hyperprolactinemia?
There is a narrow group of patients that may benefit from estrogen therapy: patients with lactotroph
microadenomas causing hyperprolactinemia and hypogonadism, not responding or not tolerating dopamine
agonist treatment; patients with hyperprolactinemia and amenorrhea due to antipsychotic agents. In such patients,
prolactin levels should be monitored regularly as there is a small risk of increasing the size of adenoma.
❍ What are the risks of complications of microadenomas versus macroadenomas during pregnancy?
The risk is small for microadenomas at about 5% to 6% level, whereas for macroadenomas it might be as high as
36%. Complications are increase in adenoma size, headache, visual impairment, and diabetes insipidus.
❍ What is the treatment of lactotroph microadenomas before and during pregnancy?
Treatment is with dopamine agonists; bromocriptine is the preferred medications as there is longer history of its
safe usage during pregnancy. The goal is to decrease prolactin level to normal before conception (patient should
attempt pregnancy after a few months of normal menses and prolactin levels) and stop the medication once
pregnancy is confirmed. Medication may be restarted (and is effective) if complications arise.
❍ Should serum prolactin measurements be performed in pregnant women with prolactinomas?
No.
❍ For asymptomatic pregnant patients with prolactinomas, what clinical testing is indicated?
None. If severe headaches or visual field changes occur, then MRI and visual field testing are recommended.
❍ Is the management of patients with macroadenomas any different from those with lactotroph
microadenomas before and during pregnancy?
Patients with a macroadenoma and those with evidence of compression of optic chiasm should be treated with
transsphenoidal surgery with possible post-op radiation before pregnancy. If complications arise during pregnancy,
the treatment of choice is bromocriptine. If the adenoma does not respond to medical therapy and vision is
severely impaired, patients undergo surgery in the second trimester or after delivery if it is diagnosed in the third
trimester. Pregnancy should be discouraged in patients not responsive to medical therapy. Follow-up depends on
size of adenoma and complications.
❍ What therapeutic options should be considered in patients desiring pregnancy but not responding to
dopamine agonists?
Transsphenoidal surgery or ovulation induction.
❍ May patients with prolactin adenomas breastfeed? Does this depend on the size of tumor?
It is safe to breastfeed with a microadenoma or if there is an asymptomatic macroadenoma. Symptomatic patients
with macroadenomas should be treated. If patients are receiving dopamine agonists, nursing should be stopped.
❍ Do patients with microadenomas or macroadenomas have increased incidence of spontaneous miscarriage
or other complications of pregnancy?
No.