HYPERPROLACTINEMIA

The Missing Period . . . . . . . . . . . Level I

Amy Heck Sheehan, PharmD
Karim Anton Calis, PharmD, MPH, FASHP, FCCP

LEARNING OBJECTIVES
After completing this case study, the reader should be able to:

• Recognize the signs and symptoms of hyperprolactinemia.

• Recommend appropriate treatment options for hyperprolactinemia.
• Design a plan to monitor the response to the pharmacologic treatment of hyperprolactinemia.

PATIENT PRESENTATION

Chief Complaint
“I haven’t had my period for almost a year.”

HPI
Susan Oliver is a 31-year-old woman with a history of oligomenorrhea (menstrual cycle every 2–6
months) since menarche at age 14. She presents to her gynecologist after 11 months of amenorrhea and
a small amount of milky discharge from her left breast, which she first noticed 1–2 months ago. The
patient and her husband would like to have a baby, but she is concerned that she may be unable to
have children. The patient states that she and her husband have not used birth control for more than 1
year, and she has had several negative home pregnancy tests.

PMH
GERD
Seasonal allergies
Depression

FH
Father died at age 58 from an AMI; mother (age 62) has type 2 DM and HTN. Patient has two
brothers (ages 33 and 35) who are alive and well.

SH
The patient is employed as an administrative assistant. She does not smoke and has less than one
drink of alcohol per month. She has been married for 5 years and lives with her husband and two
stepdaughters (ages 7 and 9).
 Meds
Omeprazole 20 mg PO daily
Desloratadine 5 mg PO daily
Fluoxetine 20 mg PO daily
Prenatal vitamins one tablet PO daily
Acetaminophen 500 mg PO PRN

All
Codeine (hives)

ROS
Galactorrhea of the left breast and amenorrhea for 11 months as described in the HPI. No visual
defects. No active GERD or migraine symptoms.

Physical Examination
Gen
The patient is a WDWN white woman in NAD

VS
BP 124/71 mm Hg, P 72 bpm, RR 13, T 37.1°C; Wt 72 kg, Ht 5′8″

Skin
Normal, intact, warm, and dry

HEENT
PERRLA, EOMI, normal funduscopic exam, normal visual fields

Neck/Lymph Nodes
Normal thyroid, no lymphadenopathy

Lungs/Chest
CTA & P

Breasts
Galactorrhea of left breast, no masses

CV
RRR, S1 and S2 normal, no MRG

Abd
Soft, nontender, no organomegaly, (+) bowel sounds

GU
LMP 11 months ago, normal pelvic exam and Pap smear
MS/Ext
Normal ROM, no edema, pulses 2+ throughout

Neuro
A & O × 3, bilateral reflexes intact, normal gait, CNs II–XII intact

Labs

Serum prolactin on 3 separate days: 133, 159, and 142 mcg/L

Other Test Results

DXA T-score –0.90 at the lumbar spine (no previous DXA results)
MRI of the pituitary gland revealed an 8-mm pituitary adenoma

Assessment
Hyperprolactinemia due to a microprolactinoma

QUESTIONS

Problem Identification
1.a. List this patient’s drug therapy problems.
1.b. What signs, symptoms, and laboratory values indicate the presence of hyperprolactinemia?
1.c. Could this patient’s hyperprolactinemia be drug-induced?

Desired Outcome
2. What are the goals of treatment for a woman with hyperprolactinemia?

Therapeutic Alternatives
3.a. What nondrug therapies can be considered for the treatment of hyperprolactinemia?
3.b. What pharmacotherapeutic options are available for the treatment of hyperprolactinemia in this
woman?

Optimal Plan
4. What medication regimen would you recommend for this patient?

Outcome Evaluation
5.a. What clinical and laboratory parameters are necessary to monitor the patient’s response to
therapy?
5.b. If the initial therapy you recommend is effective, how soon can the patient hope to become
pregnant?

Patient Education
6. What information should be provided to the patient to enhance adherence, optimize therapy, and
minimize adverse effects?

CLINICAL COURSE
The patient was started on the regimen you recommended, and she returned to the clinic 4 weeks later
complaining of significant nausea and abdominal pain that was temporally associated with medication
administration. Serum prolactin concentrations measured 10 minutes apart were 140, 151, and 137
mcg/L. Galactorrhea and amenorrhea were unchanged.

FOLLOW-UP QUESTIONS
1. Identify the possible reasons for the patient’s poor initial response to therapy.
2. Given the new patient information, what alternative therapies should be considered?
3. How long will this patient require drug treatment for the prolactinoma?

SELF-STUDY ASSIGNMENTS
1. Review the available information on the safety of dopamine agonist pharmacotherapy in pregnant
women. If this patient eventually becomes pregnant, should a dopamine agonist be continued
throughout the pregnancy?
2. Research information on the use of hormone replacement therapy in patients with
hyperprolactinemia. Is this patient a candidate for hormone replacement therapy? Why or why not?
3. Describe the treatment of hyperprolactinemia in the presence of a macroadenoma. How would the
management of hyperprolactinemia be different if the patient were diagnosed with a
macroprolactinoma instead of a microprolactinoma?

CLINICAL PEARL
Although dopamine agonists are the mainstay of therapy for hyperprolactinemia, approximately 5–
10% of patients do not respond to these agents because of poor compliance, suboptimal dosing, or the
presence of a treatment-resistant prolactinoma.

REFERENCES
1. Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an
Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:273–288.
2. Glezer A, Bronstein MD. Prolactinomas. Endocrinol Metab Clin N Am 2015;44:71–78.
3. Webster J, Piscitelli G, Polli A, et al. A comparison of cabergoline and bromocriptine in the
treatment of hyperprolactinemic amenorrhea. N Engl J Med 1994;331:904–909.
4. Colao A, Abs R, Barcena DG, et al. Pregnancy outcomes following cabergoline treatment:
extended results from a 12-year observation study. Clin Endocrinol 2008;68:66–71.
5. Molitch ME. Management of the pregnant patient with a prolactinoma. Eur J Endocrinol
2015;172:R205–R213.
6. Klibanski A. Prolactinomas. N Engl J Med 2010;362:1219–1226.