Complications
Visual field defects (bilateral hemianopia) are commonly identified in untreated patients with large macroprolactinomas compressing the optic chiasm.[32]
However, rapid improvement can occur if dopamine agonist therapy is initiated as early as possible.
Trans-sphenoidal surgery may be complicated and result in anterior pituitary failure and/or diabetes insipidus requiring permanent hormonal replacement, particularly in cases of large and invasive macroprolactinomas.
Pituitary radiotherapy is rarely used for prolactinomas as it is associated with significant long-term morbidity, including hypopituitarism.[32]
When given in very high doses, such as for Parkinson's disease, cabergoline may result in valvular heart disease, particularly valvular regurgitation.[19] However, cabergoline is usually used at much lower doses to treat prolactinomas.
Evidence does not support a significant clinical association between cabergoline treatment for prolactinomas and valvular heart disease.[20]
Patients should receive the lowest effective dose of cabergoline for the shortest possible duration. Echocardiographic surveillance may be performed on patients likely to receive moderate or high doses of cabergoline for a considerable duration.[22][23]
Although dopamine agonists are well tolerated by the majority of patients for prolactinoma management, a small number of patients may develop psychiatric disturbances, including impulse control disorders.[14] Further studies are needed to elucidate specific risk factors for the development of psychiatric disturbance with dopamine agonists, but currently clinicians are advised to monitor carefully for mood disturbance and the development of impulse control disorders. For those patients with pre-existing psychiatric disorders, dopamine agonists should be used with caution in the management of prolactinoma, and alternative treatment options, such as trans-sphenoidal surgery, should be considered.
Patients may present with acute symptoms, including severe headache, vomiting, visual impairment, ocular palsy, or death, due to acute haemorrhage into or ischaemic infarction of a large pituitary prolactinoma (pituitary apoplexy).[33][34]
Pituitary apoplexy may occur as the presenting sign. Triggers such as the use of anticoagulants, oestrogen administration, or use of dopamine agonist treatment have been reported.[34]
Many patients experience long-term symptoms, suggesting pituitary hormone dysfunction, before apoplexy.
Some patients with apoplexy of a prolactinoma, with mild symptoms and no visual deficit, improve spontaneously and can be managed conservatively with dopamine agonists and supportive care.[35]
Patients with symptomatic apoplexy may be referred for trans-sphenoidal surgery.[33]
Dopamine agonists are usually required if a patient remains hyperprolactinaemic despite trans-sphenoidal surgery for pituitary apoplexy.
Rhinorrhoea may occur as a presenting sign of large invasive macroprolactinomas or during medical treatment with high-dose dopamine agonist for these tumours.[32]
Sometimes this complication requires surgical intervention to decrease the risk for bacterial meningitis.
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