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      Managing Prolactinomas during Pregnancy

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          Abstract

          Prolactinomas are the most prevalent functional benign pituitary tumors due to a pituitary micro- or macroadenoma. The majority of patients presents with infertility and gonadal dysfunction. A dopamine agonist (DA) (bromocriptine or cabergoline) is the treatment of choice that can normalize prolactin levels, reduce tumor size, and restore ovulation and fertility. Cabergoline generally preferred over bromocriptine because of its higher efficacy and tolerability. Managing prolactinomas during pregnancy may be challenging. During pregnancy, the pituitary gland undergoes global hyperplasia due to a progressive increase in serum estrogens level that may lead to increase of the tumor volume with potential mass effect and visual loss. The risk of tumor enlargement may occur in 3% of those with microadenomas, 32% in those with macroadenomas that were not previously operated on, and 4.8% of those with macroadenomas with prior ablative treatment. Though both drugs appear to be safe during pregnancy, the data on fetal exposure to DAs during pregnancy have been reported with bromocriptine far exceeds that of cabergoline with no association of increased risk of pregnancy loss and premature delivery. It is advisable to stop the use of DAs immediately once pregnancy is confirmed, except in the case of women with invasive macroprolactinomas or pressure symptoms. This review outlines the therapeutic approach to prolactinoma during pregnancy, with emphasis on the safety of available DA therapy.

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          Most cited references 44

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          Diagnosis and treatment of hyperprolactinemia: an Endocrine Society clinical practice guideline.

          The aim was to formulate practice guidelines for the diagnosis and treatment of hyperprolactinemia. The Task Force consisted of Endocrine Society-appointed experts, a methodologist, and a medical writer. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society, The European Society of Endocrinology, and The Pituitary Society reviewed and commented on preliminary drafts of these guidelines. Practice guidelines are presented for diagnosis and treatment of patients with elevated prolactin levels. These include evidence-based approaches to assessing the cause of hyperprolactinemia, treating drug-induced hyperprolactinemia, and managing prolactinomas in nonpregnant and pregnant subjects. Indications and side effects of therapeutic agents for treating prolactinomas are also presented.
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            Advances in the treatment of prolactinomas.

            Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.
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              Maternal age and fetal loss: population based register linkage study

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                Author and article information

                Contributors
                Journal
                Front Endocrinol (Lausanne)
                Front Endocrinol (Lausanne)
                Front. Endocrinol.
                Frontiers in Endocrinology
                Frontiers Media S.A.
                1664-2392
                26 May 2015
                2015
                : 6
                Affiliations
                1Obesity, Endocrine, and Metabolism Center, King Fahad Medical City , Riyadh, Saudi Arabia
                2College of Medicine, King Fahad Medical City, King Saud bin Abdulaziz University for Health Science , Riyadh, Saudi Arabia
                3College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Science , Riyadh, Saudi Arabia
                Author notes

                Edited by: Corin Badiu, Carol Davila University of Medicine and Pharmacy, Romania

                Reviewed by: Akira Shimatsu, National Hospital Organization Kyoto Medical Center, Japan; Hidenori Fukuoka, Kobe University Hospital, Japan; Jacqueline Trouillas, University Lyon 1, France

                *Correspondence: Mussa Hussain Almalki, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, 7062, Ajman street, Riyadh 13314-3397, Saudi Arabia, m2malki@ 123456yahoo.com

                Specialty section: This article was submitted to Pituitary Endocrinology, a section of the journal Frontiers in Endocrinology

                Article
                10.3389/fendo.2015.00085
                4443771
                Copyright © 2015 Almalki, Alzahrani, Alshahrani, Alsherbeni, Almoharib, Aljohani and Almagamsi.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                Page count
                Figures: 1, Tables: 0, Equations: 0, References: 46, Pages: 5, Words: 3777
                Categories
                Endocrinology
                Mini Review

                Endocrinology & Diabetes

                pregnancy and outcome, prolactin, dopamine agonist, pituitary tumor

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