Classification by prolactinomasThe classification depends on how much the prolactinomas have increased concerning the sella turcica. There are two types of prolactinomas:
- Intrasellar micro-prolactinoma (microadenomas): less than 1 cm in diameter, not exceeding the size of the Turkish saddle
- Extrasellar macro-prolactinoma (macroadenomas): measuring more than 1 cm in diameter and exceeding the size of the sella turcica
- As a first step, the doctor will take a blood sample to understand the prolactin level. The average prolactin level is less than 25 ng/ml in women and less than 17 ng/ml in men. If the prolactin level is slightly elevated, you may need to repeat the test because even the stress and discomfort blood draw can affect the results. During the tests, the doctor will look for conditions other than prolactinoma that may increase prolactin levels and may take additional blood samples to check different hormone levels.
- The next step is to examine the pituitary gland using magnetic resonance imaging (MRI) with and without contrast. An MRI will show if there is a tumor on the pituitary gland, its size, and whether it has affected the optic nerves or other areas around the pituitary gland.
- Doctors use different terms to describe a tumor based on its size. Prolactinomas are microadenomas if they are less than 10 mm (about ½ inch), and macroadenomas if they are 10 mm or more.
- Most prolactinomas in women are microadenomas. Prolactinomas in men are more likely to be macroadenomas, but not always. Large tumors are sometimes associated with high prolactin levels (more than 1000 ng/ml).
- Macroadenomas can affect optic nerves, and men or women with large tumors may need an eye examination as part of their initial assessment.
Prolactinoma treatmentTreatment of prolactinoma aims to reduce the level of prolactin to normal. An endocrinologist treats prolactinoma and may prescribe you the most effective dopamine receptor agonists. These drugs act as dopamine to control prolactin secretion. In both women and men, the goal of pharmacotherapy is to normalize prolactin levels, restore sexual function, fertility, and reduce tumor size. The two drugs commonly used and approved for the treatment of hyperprolactinemia are Parlodel (Bromocriptine) and Dostinex (Cabergoline). In addition to the approved medicines, there is a third drug, Norprolac (Quinagolide). All approved drugs are available in generic form and are effective in reducing prolactin levels and reducing tumor size in more than 90% of patients. Prolactin levels usually return to normal within a few days, and tumor shrinkage usually appears 3-6 months after starting therapy. While both Bromocriptine and Cabergoline are effective, Cabergoline works slightly better at lowering prolactin levels and shrinking tumor size with fewer side effects. The disadvantage of Bromocriptine and Cabergoline is that discontinuation of it leads to tumor growth. It is not possible to predict which patients can safely stop taking the drug. If you have a microadenoma, your doctor will likely recommend treatment for at least two years before considering reducing or discontinuing the treatment regimen. Even after treatment discontinuation, you will need to monitor your prolactin level occasionally since the tumor may grow again. Successful long-term drug withdrawal may be possible in some patients, but patients with macroadenomas are likely to need drug therapy indefinitely. In general, surgery is not recommended as the primary therapy for prolactinomas because dopamine agonists are more effective, and surgery does not always cure the disease.
- Patients with microadenomas may need pituitary surgery if dopamine agonists do not work or if it leads to serious side effects.
- Patients with macroadenomas may require surgery if the tumor keeps growing despite drug therapy.
Prolactinoma symptoms depend on the effect of high prolactin on the reproductive system and tumor size. A large tumor can put pressure on the optic nerves or nearby brain tissue, leading to headaches or vision problems. So, the larger the prolactinoma, the more symptoms it will show.
Symptoms in women
- High prolactin levels produced by the tumor affect the ovaries' ability to produce estrogen. When estrogen levels are low, women have irregular or no menstrual periods, low sex drive, vaginal dryness, and difficulty getting pregnant.
- Due to the effect of elevated lactotrophs hormone levels on breast tissue, women who are not pregnant or breastfeeding often experience milk discharge from their breasts. This condition is called galactorrhea.
- Prolactinomas in women are small and mostly do not grow in size because of which headaches, visual symptoms, or other signs related to the tumor are rare.
Symptoms in men
- Even a small increase in prolactin levels in small pituitary tumors can lead to a decrease in libido and cause erectile dysfunction. Large tumors in men are associated with very high levels of prolactin, which almost always causes sexual dysfunction. Discharge from the chest (galactorrhea) can occur in men but are much less common than in women.
- Men with prolactinomas may also see a doctor for headaches or vision problems due to large tumors that can put pressure on the optic nerves. Due to the size of these tumors, lactotrophs hormone levels are often very high. High prolactin levels can limit the testes' ability to produce testosterone and can often cause infertility.
Reasons for the development of prolactinoma
Several conditions cause prolactinoma, but the reason behind the development of the tumor is unknown.
The potential cause can be:
- Traumatic brain injury
- Brain inflammation (due to bacterial or viral infection)
- Complications associated with granulomatous and infiltrative processes
- Metabolic disorders (linked with irreversible change or replacement of normal liver tissue with connective tissue)
- Chronic renal failure
Other conditions that cause a high level of prolactin are:-
- Prolactin-secreting adenomas
- kidney disease
- Chest injury
Who is at risk of developing prolactinoma?
For about 1 in 10,000 people, prolactinoma can develop with no known cause. Prolactinomas occur in both sexes but more commonly in women. The tumor is rare in children.
Are dopamine receptor agonists safe for long term treatment of prolactinoma?
Doctors commonly prescribe Bromocriptine and Cabergoline since it does not cause any severe complications.
What are the most common medications side effects during prolactinoma treatments?
Dopamine agonists cause side effects like nausea, low blood pressure, and dizziness. But you can avoid side effects by taking a lower dose and consuming it while sleeping or eating.
What if you leave prolactinoma untreated?
Small prolactinoma rarely grows in size, so treatment with Cabergoline or Bromocriptine is not always necessary to prevent tumor growth. However, it is critical to maintaining normal estrogen and testosterone levels to avoid low levels of sex steroids and prevent bone loss.
The doctor may recommend treatment with estrogen or testosterone instead of taking dopamine agonists. Estrogen therapy for women and testosterone therapy for men is safe. During estrogen or testosterone therapy, you will have to monitor prolactin levels.
An increase in prolactinoma tumor usually leads to a significant increase in prolactin levels and causes symptoms. If signs and symptoms are severe, you need to consult a doctor for diagnosis and treatment.
What care should I take after successful prolactinoma treatment?
Once treated with prolactinoma, you need to keep a close eye on your overall health and consult an endocrinologist once a year. You need to take a blood test twice a year to determine the level of prolactin to start treatment on time for the secondary development of the disease.