dopamine agonist
                any degree of hypogonadism / abnormal menstrual cycle
                bothersome galactorrhea (but normal menstrual cycles)
                lactotroph macroadenomas > 2de lijn transsphenoidal surgery
cabergoline most likely effective and least likely side effects
                Parkinson disease, valvular heart disease
                lowest dose of cabergoline necessary
higher than usual doses of cabergoline (eg, greater than 2 mg per week), echo cor 1x/2 jr
serum prolactin decreases to low normal: decreasing the dose as long as prolactin remains within the normal range
 
normal prolactin on low dose of dopamine agonist for at least two years: trial of stopping the drug
                idiopathic hyperprolactinemia (negative magnetic resonance imaging [MRI]) and
                lactotroph adenomas and no evidence of the adenoma by MRI for at least two years
measured after three months and yearly thereafter
increases substantially, eg, to >100 ng/mL, MRI
 
intolerance or ineffective: switching to second dopamine agonist
 
●In women with lactotroph microadenomas seeking fertility whose serum prolactin concentrations do not normalize with dopamine agonist therapy (and who therefore do not ovulate), we suggest ovulation induction with clomiphene citrate or gonadotropin therapy (Grade 2B). (See "Overview of ovulation induction".)
 
●Management of a woman with lactotroph adenomas should begin
before conception
                main concern mother adenoma growth: very small
                for the fetus exposure to dopamine agonists
lower serum prolactin concentration to normal and thereby permit ovulation
                bromocriptine: greater certainty no birth defects
                cabergoline more likely to be tolerated and more likely to be effective
macroadenoma: shrink adenoma before attempting to become pregnant
                no elevatation optic chiasm: dopamine agonist
                else: transsphenoidal surgery and then possibly radiation or dopamine agonist treatment
once pregnancy has been confirmed, stop, co a 3 mnden
                headaches and changes in vision, indien boven sella ook GV routine

●Breastfeeding is not contraindicated in women who have lactotroph adenomas, but dopamine agonists should not be used during breastfeeding because they impair lactation. An exception is a woman who has visual field impairment, who should not breastfeed and should be treated with a dopamine agonist. (See 'Breastfeeding and dopamine agonists' above.)

●We also suggest transsphenoidal surgery in women with giant lactotroph adenomas (>3 cm) who wish to become pregnant, even if the adenoma responds to a dopamine agonist (Grade 2C). The rationale for this approach is that if such a patient becomes pregnant and discontinues the agonist for the duration of pregnancy, the adenoma may increase to a clinically important size before delivery. (See 'Role of transsphenoidal surgery' above.)

●In patients with large macroadenomas who have undergone transsphenoidal debulking and in whom considerable residual adenoma remains in a location not readily accessible to surgery, we suggest radiation therapy to prevent regrowth of residual adenoma (Grade 2C). We recommend not using radiation therapy for the primary treatment of patients with macroadenomas or at all for those with microadenomas (Grade 1B). (See 'Postoperative radiation therapy' above.)

●In premenopausal women who have lactotroph microadenomas causing hyperprolactinemia and hypogonadism but who cannot tolerate or do not respond to dopamine agonists and do not want to become pregnant, we suggest estrogen and progestin replacement to prevent bone loss (Grade 2B). (See 'Role of estrogen in women' above.)

●We also suggest gonadal steroid replacement therapy in patients with hyperprolactinemia and hypogonadism due to antipsychotic agents (estradiol-progestin in women and testosterone in men) if addition of a dopamine agonist is not possible or if a satisfactory antipsychotic regimen that does not cause hyperprolactinemia cannot be found (Grade 2C). (See 'Antipsychotic drug use' above.)