Prolactinoma

Definition

Prolactinoma is a condition in which a noncancerous tumor (adenoma) of the pituitary gland in your brain overproduces the hormone prolactin. The major effect of increased prolactin is a decrease in levels of sex hormones — estrogen in women and testosterone in men.

Although prolactinoma isn't life-threatening, it can impair your vision, cause infertility and produce other effects. Prolactinoma is one of several types of tumors that can develop in your pituitary gland.

Doctors can often effectively treat prolactinoma with medications to restore your prolactin level to normal. Surgery to remove the pituitary tumor also may be an option to treat prolactinoma.

Symptoms

Sometimes, there may be no noticeable signs or symptoms from prolactinoma. When signs and symptoms are present, they may be caused by excessive prolactin in your blood (hyperprolactinemia) or, if the tumor is large, from the pressure of the tumor on surrounding tissues. Because elevated levels of the hormone prolactin cause disruption of the reproductive system (hypogonadism), some of the signs and symptoms of prolactinoma are unique for each sex.

In females

• Irregular menstrual periods (oligomenorrhea) or lack of menstrual periods (amenorrhea)
• Milky discharge from the breasts (galactorrhea) when not pregnant or breast-feeding
• Painful intercourse due to vaginal dryness

In males

• Erectile dysfunction (ED)
• Decreased body hair
• Uncommonly, enlarged breasts (gynecomastia)

In both sexes

• Low bone density
• Reduced hormone production by the pituitary gland (hypopituitarism) as a result of tumor pressure
• Loss of interest in sexual activity
• Headaches
• Visual disturbances
• Infertility

Women tend to notice signs and symptoms earlier than men do, when tumors are smaller in size, probably because they're alerted by missed or irregular menstrual periods. Men, on the other hand, tend to notice signs and symptoms later, when tumors are much larger and more likely to cause headache or vision problems.

When to see a doctor
If you develop signs and symptoms associated with prolactinoma, see your doctor to determine the cause.

Causes

Prolactinoma is one type of tumor that develops in the pituitary gland. The cause of these tumors remains unknown.

The pituitary gland is a small bean-shaped gland located at the base of your brain. Despite its small size, the pituitary gland influences nearly every part of your body. Its hormones, such as prolactin, help regulate important functions such as growth, blood pressure and reproduction.

Other possible causes of prolactin overproduction include medications, other types of pituitary tumors, an underactive thyroid gland, an injury to the chest, pregnancy and breast-feeding.

Pituitary gland and hypothalamus

Pituitary gland and hypothalamus

The pituitary gland and the hypothalamus are situated within the brain and control hormone production. ...

Endocrine system

Endocrine system

The endocrine system includes the pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreas, ovaries (in females) and testicles (in men). ...

Risk factors

Most prolactinomas occur in people between 20 and 50 years old. The disorder is rare in children. Pituitary tumors are much more likely in women than in men.

Complications

Complications of prolactinoma may include:

• Vision loss. Left untreated, a prolactinoma may grow large enough to compress your optic nerve.
• Hypopituitarism. With larger prolactinomas, pressure on the normal pituitary gland can cause dysfunction of other hormones controlled by the pituitary, resulting in hypothyroidism, adrenal insufficiency and growth hormone deficiency.
• Bone loss (osteoporosis). Too much prolactin can reduce production of the hormones estrogen and testosterone, resulting in decreased bone density and an increased risk of osteoporosis.

• Pregnancy complications. During a normal pregnancy, a woman's pituitary gland enlarges and prolactin production increases. A woman who has a large prolactinoma and becomes pregnant may experience additional pituitary growth and associated signs and symptoms, such as headaches and changes in vision.

  If you have prolactinoma and you want to become or you already are pregnant, discuss the situation with your doctor because adjustments in your treatment and monitoring may be necessary.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, you may then be referred to a doctor who specializes in disorders that affect your glands and hormones (endocrinologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements that you're taking.
• Write down questions to ask your doctor.

Your time with your doctor may be limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For prolactinoma, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• What treatments are available, and which do you recommend?
• What types of side effects can I expect from treatment?
• If I take medication, how long do I need to take it?
• Are there any alternatives to the primary approach that you're suggesting?
• If I have surgery, will the prolactinoma come back?
• I have other health conditions. How can I best manage them together?
• Will I be able to have children?
• Is there a generic alternative to the medicine you're prescribing me?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• Are you taking medications for another condition?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you or any family members ever had high calcium levels, kidney stones or tumors in other endocrine glands?

Tests and diagnosis

If you have signs and symptoms that suggest you have prolactinoma, your doctor may recommend:

• Blood tests. Blood tests can detect the overproduction of prolactin as a result of a pituitary tumor. Blood tests can also detect if levels of other hormones controlled by the pituitary are within the normal range. Women will also have a pregnancy test.
• Brain imaging. Your doctor may be able to detect a pituitary tumor on an image generated by a magnetic resonance imaging (MRI) scan of your brain.
• Tests of your vision. Such tests can determine if growth of a pituitary tumor has impaired your sight or peripheral vision.

In addition, your doctor may refer you for more extensive testing with a doctor who specializes in treating disorders of the endocrine system (endocrinologist).

Treatments and drugs

Specific goals in the treatment of prolactinoma include:

• Return the production of prolactin to normal levels
• Restore normal pituitary gland function
• Eliminate galactorrhea
• Reduce the size of the pituitary tumor
• Eliminate any signs or symptoms from tumor pressure, such as headaches or vision problems

Prolactinoma treatment consists of two main therapies, medications and surgery:

Medications
Oral medications often can decrease the production of prolactin and eliminate symptoms. Medications may also shrink the tumor. However, long-term treatment with medications is generally necessary.

Doctors use drugs known as dopamine agonists to treat prolactinoma. These drugs mimic the effects of dopamine — the brain chemical that normally controls prolactin production — but are much more potent and long lasting. Commonly prescribed medications include bromocriptine (Parlodel) and cabergoline. These drugs decrease prolactin production and may shrink the tumor in most people with prolactinoma.

Medications and pregnancy
Bromocriptine is the preferred drug when treating women who want to restore their fertility because its safety in pregnancy is well established. During pregnancy, you're doctor will likely advise you to stop taking bromocriptine or carbergoline.

Although these medications are considered safe during pregnancy, doctors generally prefer to keep medications to a minimum while you're pregnant. However, if you have a very large tumor, your doctor may recommend that you stay on your medication during your pregnancy to prevent complications from the prolactinoma. If you're being treated for prolactinoma and you'd like to start a family, it's best to discuss your options with your doctor before you become pregnant.

Medication side effects
Common side effects of these medications include lightheadedness, nausea and nasal stuffiness. However, these side effects often can be minimized if your doctor starts you with a very low dose of medication and gradually increases the dose. Rarely, cabergoline use has been associated with heart valve damage.

If medication effectively shrinks the tumor and your prolactin level remains normal afterward, you may be able to eventually stop taking the medication. Your doctor can offer you advice on when this may be possible for you.

Surgery
If drug therapy for the treatment of prolactinoma doesn't work or you can't tolerate the medication, surgery may be an option for the removal of a pituitary tumor. It may also be necessary to relieve pressure on the nerves that control your vision.

The type of surgery you have depends largely on the size and extent of your tumor:

• Transsphenoidal surgery. Most people who need surgery have a transsphenoidal procedure. In this surgery, the tumor is removed through the nasal cavity. Complication rates from this type of surgery are low because no other areas of the brain are touched during surgery, and this surgery leaves no visible scars.
• Transcranial surgery. Transsphenoidal surgery may not be best for some large tumors, or for tumors that have spread to nearby brain tissue. If this is the case for you, you may need a transcranial procedure, also known as a craniotomy. This procedure involves accessing the tumor through the upper part of the skull.

The outcome of surgery depends on the size and location of the tumor and your prolactin levels before surgery. The higher the prolactin level, the slimmer the chance that your prolactin production will return to normal after surgery. Surgery corrects the prolactin level in most people with small pituitary tumors. However, many pituitary tumors come back within five years of surgery. For people with larger tumors that can only be only partially removed, drug therapy often can return the prolactin level to a normal range after surgery.

Radiation
For people who don't respond to medication and aren't candidates for surgery, radiation therapy may be an option.