Physiological - Pregnancy, lactation, stress
Pathological:
- Prolactinoma: Most common cause of pathological hyperprolactinaemia
- Pituitary stalk compression (e.g., craniopharyngioma, sarcoidosis)
- Hypothyroidism (elevated TRH stimulates prolactin release)
- CKD, liver disease
Medications:
- Antipsychotics (most likely due to → haloperidol, paliperidone, risperidone)
- SSRIs, metoclopramide, opioids, oral contraceptives, cannabis

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Treatment

Management Based on Cause:
- Treat underlying conditions (e.g., hypothyroidism)
- Stop or substitute prolactin-raising medications if possible
Dopamine Agonist Therapy (first-line for prolactinomas):
- Cabergoline: Start with 0.5 mg weekly, increase as needed (max 3 mg/week)
- Bromocriptine: Start with 1.25 mg daily at night, titrate as tolerated
Watch-and-Wait (Nonfunctional or asymptomatic):
- For nonfunctional adenomas without symptoms or mass effect, monitor with serial MRIs and regular clinical review.
Other Options:
- Surgery: Reserved for dopamine agonist resistance or intolerance
- Radiotherapy: For persistent prolactinoma growth despite other therapies

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Notes:

Monitor serum prolactin regularly during treatment
Consider MRI if macroadenoma or prolactinoma suspected (evaluate size and pressure effects)
For antipsychotic-induced hyperprolactinaemia:
- Add small dose aripiprazole 5mg
- Dopamine agonist (needs specialist input as can precipitate psychosis)

Hyperprolactinaemia

Pathophysiology

Prolactin plays a role in over 300 functions, primarily in milk production and mammary gland development.
It also affects reproductive and immune systems.
Prolactin secretion is regulated by dopamine (inhibitory) and TRH (stimulatory) from the hypothalamus.

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Symptoms

Women: Amenorrhoea, galactorrhoea, breast tenderness.
Men: Erectile dysfunction, gynecomastia (galactorrhoea generally absent).
Both sexes: Reduced libido, infertility, and symptoms due to the mass effect of prolactinomas (e.g., headaches, visual field defects).

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Causes

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Medications:

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Diagnosis

Prolactin levels: Elevated levels confirm diagnosis; higher levels suggest macroprolactinomas.
MRI of the pituitary: To detect and assess pituitary adenomas.
Thyroid function tests (TFT): Rule out hypothyroidism.

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Management

If non-functional (not causing symptoms):

Observation with regular MRI if asymptomatic and prolactin levels are only mildly elevated.

If functional:

First-line: Dopamine agonists (Cabergoline, Bromocriptine) to reduce prolactin production.
Second-line: Surgical resection if dopamine agonists are ineffective or not tolerated.
Third-line: Radiotherapy for cases resistant to surgery and dopamine agonists.

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Notes

Use OCP as management for microprolactinomas in specific cases.
Antipsychotics are a common drug-related cause, particularly haloperidol, paliperidone, and risperidone. Adjusting the dose or switching to aripiprazole (5 mg) may reduce prolactin levels.
Monitoring visual fields and regular MRI scans are crucial for patients with prolactinomas to assess growth and effects on surrounding structures.
Visual Pathway: Prolactinomas can compress the optic chiasm, leading to visual field defects (e.g., bitemporal hemianopia).
Effect of Treatment: Dopamine agonists have been shown to reduce prolactin levels effectively in most patients, often shrinking adenomas as well.

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