Management of lactotroph adenoma (prolactinoma) during pregnancy
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Section Editors
- David S Cooper, MD
David S Cooper, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Thyroid Disease
- Professor of Medicine and International Health
- Johns Hopkins University School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Lactotroph adenomas (prolactinomas) usually cause infertility because of the inhibitory effect of elevated prolactin and sometimes because of the mass effect of a macroadenoma on gonadotropin secretion, resulting in anovulation and decreased estradiol and progesterone secretion. However, our ability to treat both of these abnormalities allows most women with this disorder to become pregnant. Management during pregnancy is based on knowledge of the risks to the mother and the fetus.
The management of women with lactotroph adenomas during pregnancy will be reviewed here. Other aspects of hyperprolactinemia and lactotroph adenomas are reviewed separately. (See "Clinical manifestations and evaluation of hyperprolactinemia" and "Causes of hyperprolactinemia" and "Management of hyperprolactinemia".)
Most women with lactotroph adenomas have anovulatory infertility and even frank hypogonadism but are able to conceive once their serum prolactin concentrations are normalized. Management should begin before lowering the prolactin concentration with a discussion about the risks of pregnancy on adenoma growth and the potential effects of exposure to dopamine agonists on the fetus. Current data suggest that neither bromocriptine nor cabergoline use during the first month of pregnancy harms the fetus. However, few data are available about the risk of either drug later in pregnancy.
Goals of treatment — The main goals of treatment for women with lactotroph adenomas considering pregnancy include:
●Women with microadenomas – Lower serum prolactin into the normal range to allow spontaneous ovulation.
- Gonzalez JG, Elizondo G, Saldivar D, et al. Pituitary gland growth during normal pregnancy: an in vivo study using magnetic resonance imaging. Am J Med 1988; 85:217.
- Gemzell C, Wang CF. Outcome of pregnancy in women with pituitary adenoma. Fertil Steril 1979; 31:363.
- Kupersmith MJ, Rosenberg C, Kleinberg D. Visual loss in pregnant women with pituitary adenomas. Ann Intern Med 1994; 121:473.
- Casanueva FF, Molitch ME, Schlechte JA, et al. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol (Oxf) 2006; 65:265.
- Molitch ME. Prolactinoma in pregnancy. Best Pract Res Clin Endocrinol Metab 2011; 25:885.
- Gillam MP, Molitch ME, Lombardi G, Colao A. Advances in the treatment of prolactinomas. Endocr Rev 2006; 27:485.
- Ahmed M, al-Dossary E, Woodhouse NJ. Macroprolactinomas with suprasellar extension: effect of bromocriptine withdrawal during one or more pregnancies. Fertil Steril 1992; 58:492.
- Ono M, Miki N, Amano K, et al. Individualized high-dose cabergoline therapy for hyperprolactinemic infertility in women with micro- and macroprolactinomas. J Clin Endocrinol Metab 2010; 95:2672.
- Weil C. The safety of bromocriptine in hyperprolactinaemic female infertility: a literature review. Curr Med Res Opin 1986; 10:172.
- Radwanska E, McGarrigle HH, Little V, et al. Induction of ovulation in women with hyperprolactinemic amenorrhea using clomiphene and human chorionic gonadotropin of bromocriptine. Fertil Steril 1979; 32:187.
- Raymond JP, Goldstein E, Konopka P, et al. Follow-up of children born of bromocriptine-treated mothers. Horm Res 1985; 22:239.
- Konopka P, Raymond JP, Merceron RE, Seneze J. Continuous administration of bromocriptine in the prevention of neurological complications in pregnant women with prolactinomas. Am J Obstet Gynecol 1983; 146:935.
- Schade R, Andersohn F, Suissa S, et al. Dopamine agonists and the risk of cardiac-valve regurgitation. N Engl J Med 2007; 356:29.
- Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:273.
- van Roon E, van der Vijver JC, Gerretsen G, et al. Rapid regression of a suprasellar extending prolactinoma after bromocriptine treatment during pregnancy. Fertil Steril 1981; 36:173.
- Liu C, Tyrrell JB. Successful treatment of a large macroprolactinoma with cabergoline during pregnancy. Pituitary 2001; 4:179.
- Bronstein MD, Salgado LR, de Castro Musolino NR. Medical management of pituitary adenomas: the special case of management of the pregnant woman. Pituitary 2002; 5:99.
- Holmgren U, Bergstrand G, Hagenfeldt K, Werner S. Women with prolactinoma--effect of pregnancy and lactation on serum prolactin and on tumour growth. Acta Endocrinol (Copenh) 1986; 111:452.
- Auriemma RS, Perone Y, Di Sarno A, et al. Results of a single-center observational 10-year survey study on recurrence of hyperprolactinemia after pregnancy and lactation. J Clin Endocrinol Metab 2013; 98:372.
- Domingue ME, Devuyst F, Alexopoulou O, et al. Outcome of prolactinoma after pregnancy and lactation: a study on 73 patients. Clin Endocrinol (Oxf) 2014; 80:642.
- Goals of treatment
- Before pregnancy
- - Discuss risk of adenoma growth
- - Macroadenomas
- Dopamine agonists to decrease size
- Indications for surgery
- - Restoration of ovulation
- Dopamine agonist therapy
- - Risks to fetus
- Choice of drug
- During pregnancy
- - Monitoring
- Serum prolactin
- Visual field testing
- Pituitary MRI
- - Treatment of enlarging adenoma
- - Pituitary apoplexy
- After pregnancy
- - Breastfeeding and dopamine agonists
- - Normalization of prolactin after pregnancy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS