Galactorrhea

Microprolactinomas can be treated in multiple ways. Asymptomatic patients who have prolactin levels < 100 mcg/L (4,348 pmol/L) and normal CT or MRI results or who have only microadenomas can probably be observed; serum prolactin often normalizes within years. Patients with hyperprolactinemia should be monitored with quarterly measurement of prolactin levels and undergo sellar MRI or CT annually for at least an additional 2 years. The frequency of sellar imaging can then be reduced if prolactin levels do not increase.

In women, indications for treatment include

In men, galactorrhea itself is rarely troublesome enough to require treatment; indications for treatment include

The initial treatment for both sexes is usually a dopamine agonist such as bromocriptine 1.25 to 5 mg orally twice a day or the longer-acting cabergoline 0.25 to 1.0 mg orally once or twice a week, which lower prolactin levels. Cabergoline is the treatment of choice because it is more easily tolerated (has a lower frequency of adverse effects) and more potent than bromocriptine. Women trying to become pregnant should stop cabergoline or bromocriptine use at the time of a positive pregnancy test result.

Quinagolide, a nonergot-derived dopamine agonist, is also an option for hyperprolactinemia. It is started at 25 mcg orally once a day and titrated over 7 days up to the usual maintenance dose of 75 mcg once a day (can increase weekly in 75 to 150 mcg increments to maximum dose 600 mcg once a day). Quinagolide should not be used by women contemplating pregnancy.

Patients with concomitant hypogonadism who elect to not use dopamine agonist therapy can be treated with estrogen (with or without a progestin, as indicated) or testosterone. Women with a microadenoma who are clinically hypoestrogenic or have low estradiol levels, can be given exogenous estrogen. Exogenous estrogen is unlikely to cause tumor expansion.

Patients with macroadenomas generally should be treated initially with dopamine agonists even in cases of large tumors with invasion and optic chiasm compression. Dopamine agonists usually shrink a prolactin-secreting tumor. Dopamine agonists will not shrink a nonfunctioning tumor causing pituitary stalk compression, although prolactin levels will decrease. If prolactin levels fall and symptoms and signs of compression by the tumor abate, no other therapy may be necessary. However, typically, larger, nonfunctioning lesions need additional treatment, usually surgery. Although dopamine agonist treatment usually needs to be continued long-term, prolactin-secreting tumors sometimes remit, either spontaneously or perhaps aided by the drug therapy. Sometimes, therefore, dopamine agonists can be stopped without a recurrence of the tumor or a rise in prolactin levels; remission is more likely with microadenomas than macroadenomas. Remission is also more likely after pregnancy.

High doses of dopamine agonists, particularly cabergoline and pergolide, are thought to have caused valvular heart disease in some patients with Parkinson disease Parkinson Disease Parkinson disease is a slowly progressive, degenerative disorder characterized by resting tremor, stiffness (rigidity), slow and decreased movement (bradykinesia), and eventually gait and/or... read more . Studies evaluating the lower doses of dopamine agonists used for hyperprolactinemia have not demonstrated an increased risk of valvular heart disease, but the possibility should be discussed with patients, and echocardiographic surveillance should be considered, especially when doses > 3 mg per week are used. The risk may be less with bromocriptine or quinagolide. Dopamine agonists in the doses used for hyperprolactinemia also sometimes cause behavioral and psychiatric changes, characterized by increased impulsivity and occasionally psychosis, and this limits their use in some patients.

Surgery is second-line therapy in patients whose tumor is resistant to dopamine agonists or patients are intolerant of medical therapy.

Radiation therapy should be used only in patients with progressive disease who do not respond to other forms of therapy. With irradiation, hypopituitarism often develops several years after therapy. Monitoring endocrine function and sellar imaging are indicated yearly for life.

Women should stop dopamine agonists (cabergoline or bromocriptine) at the time of a positive pregnancy test result because the potential risk of fetal harm from the drug outweighs the risk of pituitary tumor growth, and prolactin naturally rises during pregnancy. It may be prudent to continue dopaminergic therapy throughout pregnancy, especially if the tumor is invasive or abutting the optic chiasm. During pregnancy, about 30% of macroadenomas enlarge; and normal pituitary tissue expands. If patients have clinical evidence of tumor expansion (headaches and/or visual field loss) and enlargement is confirmed by MRI, then dopaminergic therapy probably should be re-started. The Endocrine Society guidelines (1 Treatment reference Galactorrhea is lactation in any men or in women who are not breastfeeding. It is generally due to a prolactin-secreting pituitary adenoma. Diagnosis is by measurement of prolactin levels and... read more ) recommend using bromocriptine but many experts use cabergoline, particularly if it was used before the pregnancy; there is no evidence of adverse outcomes to either fetus or mother.