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Galactorrhea
- Occurs in 90% of women with Hyperprolactinemia
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Amenorrhea
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Infertility
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Galactorrhea with Amenorrhea is pathognomonic for Hyperprolactinemia
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Galactorrhea without Amenorrhea is associated with normal Serum Prolactin
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MRI Brain with IV contrast
- Thin cuts through the sella turcica, Hypothalamus and Optic Chiasm
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CT Head with cone down sella turcica
- Lower Test Sensitivity than MRI for Pituitary Adenoma and associated abnormalities
- Approach
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Initial Evaluation
- See Galactorrhea
- Confirm Hyperprolactinemia
- Repeat Serum Prolactin
- Repeat in 6 months if repeat Prolactin normal
- Evaluate for Physiologic Cause
- History
- Breast stimulation or Lactation
- Sexual Intercourse temporally related to lab test
- Excessive Eating, Exercise, Sleep or Stress
- Labs
- Thyroid Stimulating Hormone (Hypothyroidism)
- Urine Pregnancy Test
- Comprehensive Metabolic Panel (Electrolytes, Serum Creatinine, hepatic panel)
- Evaluate for liver disease and renal disease
- Consider reproductive Hormone levels if Hypogonadism is present
- Serum Estrogen
- Serum Testosterone
- Follicle Stimulating Hormone
- Luteinizing Hormone
- Abnormal Serum Prolactin >18 ng/ml in men, >20 ng/ml postmenopausal women, >30 ng/ml in premenopausal women
- Identify medication related Hyperprolactinemia cause
- Discontinue Medication Causes of Hyperprolactinemia
- Repeat Prolactin in 1-2 months (at least 3 days after medication discontinuation)
- No obvious medication cause
- Recheck Serum Prolactin in 3 months
- Consider lab testing as above (e.g. TSH, HCG)
- Identify medication related Hyperprolactinemia cause
- Discontinue offending medication
- Repeat Prolactin in 1-2 months
- No obvious medication cause
- Obtain CT or MRI Head (cone-down sella turcica)
- Imaging Abnormal
- Evaluate Pituitary Tumor (see Prolactinoma)
- Imaging Normal
- Consider Dopamine Agonist (e.g. Bromocriptine, Cabergoline)
- Symptomatic Hyperprolactinemia (e.g. bothersome Galactorrhea or Amenorrhea)
- Consider hormonal therapy (Estrogen or Testosterone)
- Hypogonadism
- Repeat evaluation and testing
- Repeat Prolactin at 6 month intervals
- Repeat CT or MRI Head (cone-down sella) in 1 year
- Causes
- Empty sella syndrome
- Pituitary Adenoma (especially if >200 to 250 ng/ml)
- Consider medication related Hyperprolactinemia
- Less likely to raise the Serum Prolactin this high
- Obtain CT or MRI Head (cone-down sella turcica)
- Imaging Abnormal
- Evaluate Pituitary Tumor (see Prolactinoma)
- Imaging Normal
- Treatment with Dopamine Agonist (e.g. Bromocriptine, Cabergoline)
- Repeat Serum Prolactin every 3 months
- Repeat CT or MRI Head (cone-down sella) in 1 year
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Osteoporosis (secondary to Hypogonadism)
- Consider Bone density scan (DEXA)
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