TOG: Hyperprolactinaemia and reproductive function

Question 1

What is the main inhibitory factor of prolactin?

Answer 1

dopamine

Question 2

How long after pregnancy do PRL levels return to normal?

Answer 2

6 months after delivery

Question 3

how do high levels of PRL lead to infertility?

Answer 3

high PRL results in inhibition of ovulation due to inhibition of LH pulsatility

Question 4

how does hyperprolactinaemia usually present?

Answer 4

oligo-/amenorrhoea/ infertility/ galactorrhoea

Question 5

in women with hyperprolactinaemia, in what percentage of cases is ovulation restored after treatment with dopamine agonists?

Answer 5

90%

Question 6

what percentage of women go on to get pregnant after restoring ovulation in women with hyperprolactinaemia?

Answer 6

80-85%

Question 7

what is the incidence of hyperprolactinaemia in infertile but ovulatory women?

Answer 7

3.8-11.5%

Question 8

what are the 4 main causes of hyperprolactinaemia?

Answer 8

1. pituitary disease- PRLoma/ cushings/ acromegaly
2. hypothalamic disease- tumours/ meningioma/ TB/ irradiation
3. medications- neuroleptics/ anti-emetics/ methyldopa, verapamil/ TCA’s/ cimetidine/ estrogens
4. other- PCOS/ hypothyroid/ renal failure/ idiopathic/ stress

Question 9

if levels of PRL are <2000, what is usually the cause of hyperPRL?

Answer 9

disconnection hyperPRL- raised PRL due to disruption of dopaminergic inhibition of pituitary lactotrophs. Cause; non-functioning adenomas

Question 10

if PRL level >2000, what is the common cause?

Answer 10

PRL-secreting tumours

Question 11

what percentage of the normal population will have radiological evidence of pituitary adenoma?

Answer 11

10%

Question 12

when in MRI indicated in raised PRL?

Answer 12

if PRL level>1000 with clinical / biochemical effects of pituitary disease

Question 13

in what percentage of women taking bromocriptine for hyperPRL, is ovulation restored?
in what % cases does bromocriptine reduce size of PRLoma?

Answer 13

80-90% ovulation restored

in 70% cases PRL is reduced in size

Question 14

what are the side effects of bromocriptine?

Answer 14

nausea, vomiting, postural hypotension

Question 15

why is cabergoline preferred over bromocriptine for treating hyperPRL?

Answer 15

more effective than bromocriptine in lowering lipid levels.
fewer side effects.
given 1-2x/week

Question 16

what is the main adverse effect of cabergoline if taken long term?

Answer 16

cardiac valvular insufficiency

Question 17

what advice is given to people taking cabergoline long term, with regards to their heart?

Answer 17

6-12 monthly cardiac echo for ppl taking cabergoline

Question 18

in what percentage of women does ovulation resume with taking cabergoline for hyperprolactinaemia?
In what percentage of cases is tumour size reduced?

Answer 18

95%- return of ovulation

tumour reduced in 80% cases

Question 19

what are the indications for surgery in hyperprolactinaemia?

Answer 19

1. failed medical therapy
2. expanding PRLoma with ophthalmological/ neurological defecit, not repsonding to medical Tx
3. pituitary apoplexy- infarction/haemorrhage into PRLoma

Question 20

In what percentage of cases is surgery successful for macro and micro PRLomas?

Answer 20

microprolactinoma= 75%
macroprolactinoma= 34-38%

Question 21

what is the first line treatment for women with hyperprolactinaemia who wish to become pregnant?

Answer 21

bromocriptine

Question 22

what is the risk of clinically sig increase in size of microPRLoma in pregnancy?

Answer 22

2.6%

Question 23

what is the risk of clinically sig increase in size of MACROPRLoma in pregnancy?
what percentage of these will require surgery?

Answer 23

30-35%.

8.5% of these will require surgery

Question 24

if woman has been taking bromocriptine prior to pregnancy for microprolactinoma, what advice is given with regards to the medication and further management?

Answer 24

stop bromocriptine early in pregnancy, most have very low risk of tumour expansion.
MRI is done if woman develops visual symptoms of mass expansion

Question 25

what advice is given to women with macroprolactinomas who become pregnanct?

Answer 25

carry on with medical treatment throughout pregnancy, monitor visual fields each trimester