MANAGEMENT OF A PROLACTINOMA —16 February 2014

MANAGEMENT OF A PROLACTINOMA ---16 February 2014
QUESTION-May I request your valuable input on this case. She is a 28-year-old referred with irregular periods. I noted elevated prolactin since 2011.
July 2011: Prolactin 1460 mIU/L (normal 40-570)
June 2013: Prolactin 1120 mIU/L No macroprolactin was reported
There was no galactorrhoea. Hormonal workup and U/S pelvis was not consistent with PCOS. TSH was normal. MRI pituitary revealed 5x4 mm right microadenoma of pituitary gland. She was commenced on small dose Cabergoline 0.5 mg per week. Her periods became regular and follow up prolactin levels
July 2013: 141 mIU/L
Oct 2013: 114 mI/U/L
She complained of nausea and breast tenderness with treatment. I changed her cabergline to 0.25 mg twice per week. While on Cabergoline she has had two repeat MRI pituitary over 8 months with no change in pituitary microadenoma. She had symptomatic and biochemical resolution and persistent but stable MRI pituitary microadenoma.What would you recommend about further management. She would also like to become pregnant. Thank you very much. Dr Irfan  Aziz Shaikh
RESPONSE--It seems like you have done all the right things.  She has a prolactin-secreting microadenoma causing oligomenorrhea and has responded well to a small dose of cabergoline.  I would just continue the current treatment for now and would not repeat any MRI scans.  If she wishes to become pregnant, just continue the cabergoline until she misses a period and has a positive pregnancy test.   Then discontinue the cabergoline and follow her symptomatically every 3 months during the pregnancy without measuring any prolactin levels.  The risk of clinically significant tumor enlargement is 2.7%.  If she develops progressively severe headaches or any visual symptoms, then obtaining visual field testing and an MRI would be warranted.  If there is significant tumor growth, reinstitution of cabergoline would be indicated. Mark E. Molitch, M.D.