Manage a Prolactinoma:

  1. Best initial step – medications: Bromocriptine or Cabergoline
    1. Monitor response to therapy with periodic serum prolactin levels.
  2. If failure to respond to medical therapy – surgery: Transsphenoidal surgery.
  • First-line therapy is medication > surgery (even if severe mass effect with vision loss)
    • Treat with Dopamine Agonists (DA): Bromocriptine and Cabergoline.
      • Decrease the size and hormone production of prolactinomas rapidly.
      • Monitor response to therapy: Check serum prolactin level 1 month after starting therapy and then every 3-4 months.
        • Decreasing serum prolactin usually correlates with decreasing size of the tumor.
        • Microprolactinomas:
          • Repeat MRI in 1 year (if prolactin level normalizes on DA).
          • After tumor shrinkage is confirmed, additional MRIs are not necessary unless serum prolactin level rises.
        • Macroprolactinomas:
          • Repeat MRI in 3 months after starting medication or if prolactin levels are rising on therapy with good medication adherence.
          • Repeat MRI every 6-12 months until the macroprolactinoma is stable on serial studies and the prolactin level is not rising.
        • Taper therapy after the prolactin level has been normal for 2 years, and there is no longer a visible tumor on pituitary MRI.
          • After discontinuing the dopamine agonist:
            • Follow prolactin levels:
              • Once a month for 3 months
              • Every 3 months for the 1st year
              • Annually then on.
            • Pituitary MRI:
              • Repeated if the prolactin level rises above normal.

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