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Prolactinoma: Early Detection, Evaluation and Management

CLINICAL ACTIONS:

Prolactinomas are generally benign prolactin-secreting tumors and account for 40-66% of all pituitary adenomas.  The vast majority are microadenomas (diameter < 1cm) and suppress the hypothalamic-pituitary gonadal hormonal axis, while 10% are macroadenomas (≥ 1cm) and may cause additional mass effects due to size. Age prevalence varies widely, but they are commonly found in women during childbearing years, in part due to development of menstrual irregularities. Despite their benign nature, if diagnosis is delayed bone loss and vertebral fractures can occur, and the loss of bone density can be permanent.

Clinical signs and symptoms: 

  • Oligo or amenorrhea
  • Galactorrhea and gynecomastia
  • Loss of libido and erectile dysfunction 
  • Infertility
  • Decreased bone density
  • Mass effect:
    • Headache
    • Visual field abnormalities

Evaluation:

  • Endocrine Society practice guideline
    • “To establish the diagnosis of hyperprolactinemia, we recommend a single measurement of serum prolactin; a level above the upper limit of normal confirms the diagnosis as long as the serum sample was obtained without excessive venipuncture stress” 
  • History should be obtained to rule out obvious causes of elevated prolactin such as medications 
  • MRI pituitary with and without contrast to assess size and type of tumor
  • Prolactin levels
    • Prolactin levels above 200 µg/L is usually a prolactinoma
    • Prolactin levels above 500 µg/L likely indicates a macroprolactinoma
    • Prolactin macroadenomas can present with a falsely normal prolactin level due to the “hook effect” (false negative levels if excessive amount of analyte is present) 
    • When prolactin values are lower than expected in a patient, consider discussion with endocrinologist or clinical pathologist for further guidance
  • Non-prolactin secreting pituitary adenomas can cause pituitary stalk or hypothalamus compression and consequent prolactinemia 
  • TSH, free thyroxine (FT4), and creatinine levels to exclude secondary causes 

Treatment:

  • Minimal symptoms (mild galactorrhea and normal menses): observation and monitor q6-12 months may be acceptable
  • Oligo or amenorrhea (pregnancy not desired): oral contraceptives or other estrogen/progesterone combinations
  • Most patients placed on dopamine agonists
    • Cabergoline > bromocriptine in reducing prolactin levels
    • Nearly 80% of patients treated with dopamine agonists will normalize prolactin level and reduce the size of their adenoma 
  • Transsphenoidal surgery
    • Can result in normal prolactin levels in majority of microadenomas and up to 40% in macroadenomas
    • Recommended: When dopamine agonists not tolerated/desired | Acute tumor complications |Visual deficits not corrected with medical therapy 
    • Recurrence is possible (20% over 10 years)
  • Radiotherapy
    • Rarely used for those cases that do not respond to the above
  • Chemotherapy
    • Temozolamide rarely used with limited success
  • Follow Up
    • Once prolactin levels have improved monitoring is recommended with repeat prolactin levels every 3 to 6 months for the first year and then every 6 to 12 months thereafter 
    • MRI should be repeated in 1 year for microadenomas or 3 months for macroadenomas after medical therapy is initiated 
    • Therapy may be tapered after 2 years of treatment for patients with normal prolactin levels and no visible tumor on MRI 
    • Recurrence rates after stopping dopamine agonists is between 26 to 69% and most likely to occur in the first year, and should be monitored with serial prolactin measurements every 3 months for the first year and annually thereafter 

SYNOPSIS:

The prevalence of prolactinomas is reported to be between 35 to 50 per 100,000.  They are most commonly seen in women (10:1 ratio female/male) and the usual age range is between 20 to 50 years of age. Dopamine originating in hypothalamic neurons is a principal inhibitory regulator of prolactin release by pituitary lactotrophs and this pathway is the basis of medical treatments.  Fortunately, only a minority of microadenomas will continue to grow (< 10%) but early detection, monitoring and a management plan, which may be multidisciplinary, is required for good outcomes. Consider accessing expertise in endocrinology and radiology to ensure correct differential between prolactinoma and non-secreting pituitary adenoma as treatment for the latter is usually surgical, not medical.

KEY POINTS:

Severe adverse effects of dopamine inhibitors are unusual but cabergoline may include compulsive behavior (e.g. excessive gambling) as well as cardiac valvular abnormalities at high doses

  • Other causes of hyperprolactinemia include
    • Pituitary disorders (e.g. Cushing disease)
    • Hypothalamic disorders (e.g. non-secreting pituitary adenoma)
    • Neurogenic (e.g. chest wall or spinal cord lesions)
    • Medical
      • Hypothyroidism
      • Chronic kidney disease
      • Cirrhosis
    • Medications
      • Antipsychotics (e.g. phenothiazines)
      • Antidepressants (e.g. tricyclics, MAOIs, SSRIs)
      • Antihypertensives (e.g. verapamil, labetolol)
      • Anticonvulsants (e.g. phenytoin)
      • Prokinetics (e.g. metoclopramide)
      • Hormones (e.g. estrogen)
      • H2 blockers (e.g. cimetidine, ranitidine)
      • Controlled substances (e.g. opiates, cocaine, marijuana)
      • Other (e.g. alcohol)

Learn More – Primary Sources:

Orphanet J Rare Disease: The risks of overlooking the diagnosis of secreting pituitary adenomas

Diagnosis and Treatment of Pituitary Adenomas: A Review

Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas 

Diagnosis and Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline 

Prolactinoma Management 

The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new 

Underappreciation of the “Hook Effect” leading to Mismanagement of a Patient, a Tale of Preventable Disaster 

Optimizing Contraception for the HIV-positive Woman

The ideal contraceptive for an HIV-positive woman prevents pregnancy as well as transmission of HIV and STDs.  Dual contraception using condoms plus an additional contraceptive is the best strategy. Preexposure (PrEP) and postexposure (PEP) prophylaxis should be available to partners regardless of contraceptive method used.

There does not appear to be an association between the use of non-injectable hormonal contraception and risk of HIV acquisition. Studies regarding the risk of HIV acquisition with the use of progestin only DMPA injectable are conflicting, and the CDC continues to recommend it.

SUMMARY:

  • Combined hormonal contraception (pill, patch and ring) and progestin-only pills
    • Considered MEC cat. 1 for patient who are not on antiretrovirals or are not clinically well
    • For patients who are taking antiretrovirals, can decrease hormone levels but are still considered safe (either cat. 1 or 2 depending on which antiretroviral is being used)
    • Protease inhibitors, pharmacologic boosters, and efavirenz can cause decreased effectiveness of hormonal contraception
    • Fostemsavir: can cause increased levels of ethinyl estradiol and raise risk of thromboembolic events. Dosing of ethinyl estradiol should not be higher than 30 mcg daily.
  • Contraceptive implants are highly effective and benefits outweigh risks in HIV positive women (MEC cat. 1)
  • Injectable depot medroxyprogesterone acetate (DMPA) is safe and effective (MEC cat. 1) and does not appear to have interactions with antiretrovirals
    • Studies regarding increased risk of HIV transmission and acquisition are conflicting.
  • Intrauterine devices, both copper containing and levonorgestrel-releasing
    • MEC cat. 1 for women with HIV who are clinically well and on antiretrovirals, with no known drug interactions with antiretrovirals
    • For women with HIV who are not clinically well or not on antiretrovirals, initiation of IUD is considered MEC cat. 2, but continuation for an already placed IUD is cat.1
    • Limited data suggest a low risk of pelvic inflammatory disease and no changes in genital shedding of HIV RNA
  • Condoms reduce transmission of HIV between discordant partners but are not represent optimal contraception, with an annual pregnancy rate of over 15% per year. Should be used concurrently with another contraceptive method
  • Spermicides: not recommended due to potential of causing genital lesions
    • Nonoxynol-9, the active ingredient in most formulations, can cause genital lesions and may increase the likelihood of HIV transmission to a partner

KEY POINTS:

  • HIV infection does not pose a barrier to sterilization, which remains an appropriate contraceptive option
  • Emergency contraception including hormone based (progestin-only pills, ulipristal acetate, combined oral contraceptives) and the copper IUD should be offered to HIV positive women whenever appropriate
  • Spermicides and are not recommended

Learn More – Primary Sources:

CDC United States medical eligibility criteria for contraceptive use, 2016

Contraception: Contraceptive failure in the United States

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV

HIV in Women: National HIV Curriculum