Guideline sources The following summarized guidelines for the evaluation and management of hyperprolactinemia are prepared by our editorial team based on guidelines from the European Society of Endocrinology (ESE 2021), the European Thyroid Association (ETA 2018), and the Endocrine Society (ES 2011). 1 2 3 Guidelines 1. Screening and diagnosis Diagnosis: obtain a single measurement of serum prolactin for the diagnosis of hyperprolactinemia and confirm the diagnosis with a level above the ULN as long as the serum sample is obtained without excessive venipuncture stress. A Differential diagnosis: Exclude the following causes in patients with symptomatic non- physiological hyperprolactinemia: medication use renal failure hypothyroidism parasellar tumors. A https://web.pathway.md/diseases/rechvfZS1fT3Z9dog 1/4 6/24/23, 12:45 PM Hyperprolactinemia Pathway pa ase a tu o s 2. Diagnostic investigations Serum prolactin levels: obtain a single measurement of serum prolactin for the diagnosis of hyperprolactinemia. A Show 3 more Screening for central hypothyroidism: obtain screening for central hypothyroidism in patients with hyperprolactinemia and hypothyroid manifestations. A 3. Medical management Dopamine agonists: initiate dopamine agonist therapy to lower prolactin levels, decrease tumor size, and restore gonadal function in patients with symptomatic prolactin-secreting microadenomas or macroadenomas. A Show 7 more Oral contraceptives: consider initiating oral contraceptives for the treatment of patients with amenorrhea caused by a microadenoma. C 4. Therapeutic procedures Radiotherapy: consider offering radiation therapy in patients failed surgical treatment or with aggressive or malignant prolactinomas. C 5. Surgical interventions Transsphenoidal surgery: consider performing transsphenoidal surgery in symptomatic patients with prolactinomas not tolerating high doses of cabergoline or not responsive to dopamine agonist therapy. C 6. Specific circumstances Patients contemplating pregnancy: As per ESE 2021 guidelines, manage female patients of reproductive age contemplating pregnancy with a diagnosis of pituitary adenoma, functioning or nonfunctioning, by an endocrinologist. B Show 3 more As per ES 2011 guidelines: Counsel female patients with a macroprolactinoma not showing pituitary tumor shrinkage during dopamine agonist therapy or not tolerating bromocriptine or cabergoline about the https://web.pathway.md/diseases/rechvfZS1fT3Z9dog 2/4 6/24/23, 12:45 PM Hyperprolactinemia Pathway potential benefits of surgical resection before attempting pregnancy. B Instruct female patients with prolactinomas to discontinue dopamine agonist therapy as soon as pregnancy is identified. B Pregnant patients, monitoring: As per ESE 2021 guidelines, do not measure prolactin during pregnancy. D Show 4 more As per ES 2011 guidelines, do not assess serum prolactin levels during pregnancy in patients with prolactinomas. D Show 2 more Pregnant patients, management: As per ESE 2021 guidelines, discontinue dopamine agonists once pregnancy is established. Consider continuing dopamine agonists for a longer gestational period in specific circumstances. B Show 3 more As per ES 2011 guidelines: Consider continuing dopaminergic therapy throughout the pregnancy in selected patients with macroadenomas with no prior history of undergoing surgery or radiation therapy, especially if the tumor is invasive or is abutting the optic chiasm. B Initiate bromocriptine therapy in patients experiencing symptomatic growth of a prolactinoma during pregnancy. B Pregnant patients (delivery and breastfeeding): consider providing standard obstetrical care with close maternal and fetal surveillance in pregnant patients with pituitary adenomas. C Show 2 more Patients with drug-induced hyperprolactinemia: consider discontinuing medication for 3 days or substituting with an alternative followed by re-measurement of serum prolactin in symptomatic patients with suspected drug-induced hyperprolactinemia. C Show 6 more Patients with malignant prolactinoma: Consider offering radiation therapy in patients with aggressive or malignant prolactinomas. C Consider offering temozolomide in patients with malignant prolactinomas. C References 1. A Luger, L H A Broersen, N R Biermasz et al. ESE Clinical Practice Guideline on functioning and nonfunctioning pituitary adenomas in pregnancy. Eur J Endocrinol. 2021 Aug 23;185 3 G1 G33. Open 2. Melmed S, Casanueva FF, Hoffman AR et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Feb;96 2 273 88. Open 3. Persani L, Brabant G, Dattani M et al. 2018 European Thyroid Association ETA Guidelines on the Diagnosis and Management of Central Hypothyroidism. Eur Thyroid J. 2018 Oct;7 5 225 237. Open https://web.pathway.md/diseases/rechvfZS1fT3Z9dog 3/4 6/24/23, 12:45 PM Hyperprolactinemia Pathway 4. A Luger, L H A Broersen, N R Biermasz et al. ESE Clinical Practice Guideline on functioning and nonfunctioning pituitary adenomas in pregnancy. Eur J Endocrinol. 2021 Aug 23;185 3 G1 G33. Open https://web.pathway.md/diseases/rechvfZS1fT3Z9dog 4/4