Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

pre-menopausal women

1st line – observation

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ONGOING
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pre-menopausal women
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asymptomatic microprolactinomas, normal menstrual cycle, and who do not desire pregnancy
1st line – 

observation

Women who are asymptomatic and have normal menstrual cycles may be monitored and do not require treatment.[11]

1st line – dopamine agonist

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ONGOING
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pre-menopausal women
|
symptomatic microprolactinomas who do not desire pregnancy
1st line – 

dopamine agonist

Medical treatment with dopamine agonists is considered the first-line therapy for prolactinomas.[11]

Even in women who do not desire pregnancy, dopamine agonists are considered initially to treat other symptoms (e.g., troublesome galactorrhoea).

The patient should be aware that treatment may result in return of fertility and alternative forms of contraception may be required.

Treatment usually starts at low doses to avoid adverse effects, with a gradual dose escalation during the first months upon achieving control of the hyperprolactinaemia and tumour shrinkage.

A trial of dopamine agonist withdrawal is most likely to be successful if attempted in patients in whom there has been restoration of normal serum prolactin, significant reduction in tumour size on magnetic resonance imaging, maintenance of normal serum prolactin using a low dose of dopamine agonist, and a treatment duration of at least 2 years.[11][25]

Remission of hyperprolactinaemia in patients with prolactinoma following dopamine agonist withdrawal varies between studies, with greater success in microprolactinomas (approximately 40%) compared with macroprolactinomas (approximately 30%).[25]

Cabergoline is the recommended first-line dopamine agonist due to superior efficacy in normalising serum prolactin and reducing tumour size, better tolerability, and more convenient dosing regimen.[11][13]

Primary options

cabergoline: 0.25 mg orally twice weekly or 0.5 mg orally once weekly initially, increase by 0.5 mg/dose increments every 4 weeks, increase dose gradually until desired reduction in prolactin levels and/or tumour

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Secondary options

bromocriptine: 1.25 to 2.5 mg/day orally initially, increase by 2.5 mg/day increments every 2-7 days, increase dose gradually until desired reduction in prolactin levels and/or tumour

2nd line – combined oral contraceptive

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ONGOING
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pre-menopausal women
|
symptomatic microprolactinomas who do not desire pregnancy
2nd line – 

combined oral contraceptive

There are no controlled trials to compare the use of dopamine agonists and the combined oral contraceptive pill in women with microprolactinomas and oligo-/amenorrhoea. If women with microadenomas have no symptoms beside menstrual irregularities and do not desire pregnancy, then oestrogen with cyclical progesterone therapy may be considered (e.g., oestrogen/progesterone combined oral contraceptive pill), without dopamine agonist therapy. Besides providing contraception, this treatment is used to achieve menstrual regularity.

3rd line – trans-sphenoidal surgery

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ONGOING
|
pre-menopausal women
|
symptomatic microprolactinomas who do not desire pregnancy
3rd line – 

trans-sphenoidal surgery

Trans-sphenoidal surgery may be considered for those who do not tolerate dopamine agonists or whose symptoms are not responding to dopamine agonists.[11][18]

Trans-sphenoidal surgery may be complicated and result in anterior pituitary failure and/or diabetes insipidus requiring permanent hormonal replacement, although this is more likely in cases of large and invasive macroadenomas.

Dopamine agonist therapy may need to be continued following surgery if symptomatic hyperprolactinaemia persists.

4th line – sellar radiotherapy

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ONGOING
|
pre-menopausal women
|
symptomatic microprolactinomas who do not desire pregnancy
4th line – 

sellar radiotherapy

Radiotherapy is rarely used and is reserved for situations where medical and surgical treatments have failed, and for the rare cases of malignant prolactinomas.[11]

Both conventional radiotherapy and stereotactic radiotherapy do not achieve more than 20% to 40% prolactin normalisation rate in patients with prolactinomas.[17] Thus, most prolactin-secreting adenomas are radioresistant, and this mode of therapy is not an acceptable primary treatment for prolactinomas.

Pituitary radiotherapy is associated with significant long-term morbidity, including hypopituitarism (up to 50% after 10-20 years), cerebrovascular accidents, optic nerve damage, cognitive deterioration, and secondary radiation-induced brain malignancies.

1st line – dopamine agonist

Back
ONGOING
|
pre-menopausal women
|
microprolactinomas who desire pregnancy, or macroprolactinomas
1st line – 

dopamine agonist

Medical treatment with dopamine agonists is considered the first-line therapy for prolactinomas in women.[11]

Treatment usually starts at low doses to avoid adverse effects, with a gradual dose escalation during the first months with the aim of achieving control of the hyperprolactinaemia and tumour shrinkage.

Macroprolactinomas usually require higher doses of dopamine agonist compared with microprolactinomas.

Cabergoline is the recommended first-line dopamine agonist due to superior efficacy in normalising serum prolactin and reducing tumour size, better tolerability, and more convenient dosing regimen.[11][13]

There is minimal risk of microprolactinoma enlargement in pregnancy and therefore dopamine agonists can be stopped once pregnancy is confirmed.[11] Because risk of enlargement of macroprolactinomas in pregnancy is greater (20% to 30%), dopamine agonists may be continued throughout pregnancy or recommenced if visual fields deteriorate.[15] Prolactin increases in pregnancy and therefore serum prolactin measurements are not useful in monitoring prolactinoma patients during pregnancy. Both bromocriptine and cabergoline have been shown to be safe in pregnancy.[14][15]

A trial of dopamine agonist withdrawal is most likely to be successful if attempted in patients in whom there has been restoration of normal serum prolactin, significant reduction in tumour size on magnetic resonance imaging, low maintenance doses of dopamine agonists, and a treatment duration of at least 2 years.[11][25]

Remission of hyperprolactinaemia in patients with prolactinoma following dopamine agonist withdrawal varies between studies, with greater success in microprolactinomas (approximately 40%) compared with macroprolactinomas (approximately 30%).[25] Therefore, in a woman with a prolactinoma who is planning pregnancy, it may be sensible to defer plans for a trial of dopamine agonist withdrawal until she has completed her family.

Primary options

cabergoline: 0.25 mg orally twice weekly or 0.5 mg orally once weekly initially, increase by 0.5 mg/dose increments every 4 weeks, increase dose gradually until desired reduction in prolactin levels and/or tumour

More

Secondary options

bromocriptine: 1.25 to 2.5 mg/day orally initially, increase by 2.5 mg/day increments every 2-7 days, increase dose gradually until desired reduction in prolactin levels and/or tumour

2nd line – trans-sphenoidal surgery

Back
ONGOING
|
pre-menopausal women
|
microprolactinomas who desire pregnancy, or macroprolactinomas
2nd line – 

trans-sphenoidal surgery

Trans-sphenoidal surgery may be considered for those who do not tolerate dopamine agonists or whose symptoms are not responding to dopamine agonists.[11][18]

Trans-sphenoidal surgery may be complicated and result in anterior pituitary failure and/or diabetes insipidus requiring permanent hormonal replacement, although this is more likely in cases of large and invasive macroadenomas.

Dopamine agonist therapy may need to be continued following surgery if symptomatic hyperprolactinaemia persists.

3rd line – sellar radiotherapy

Back
ONGOING
|
pre-menopausal women
|
microprolactinomas who desire pregnancy, or macroprolactinomas
3rd line – 

sellar radiotherapy

Radiotherapy is rarely used and is reserved for situations where medical and surgical treatments have failed, and for the rare cases of malignant prolactinomas.[11]

Both conventional radiotherapy and stereotactic radiotherapy do not achieve more than 20% to 40% prolactin normalisation rate in patients with prolactinomas.[17] Thus, most prolactin-secreting adenomas are radioresistant, and this mode of therapy is not an acceptable primary treatment for prolactinomas.

Pituitary radiotherapy is associated with significant long-term morbidity, including hypopituitarism (up to 50% after 10-20 years), cerebrovascular accidents, optic nerve damage, cognitive deterioration, and secondary radiation-induced brain malignancies.

post-menopausal women

1st line – observation

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ONGOING
|
post-menopausal women
|
microadenomas
1st line – 

observation

Post-menopausal women with microadenoma or undetectable pituitary mass do not usually require any treatment.

Any galactorrhoea usually improves when oestrogens decrease post-menopausally.

1st line – dopamine agonist

Back
ONGOING
|
post-menopausal women
|
macroadenomas
1st line – 

dopamine agonist

Medical treatment with dopamine agonists is considered the first-line therapy.[11]

Treatment usually starts at low doses to avoid adverse effects, with a gradual dose escalation during the first months with the aim of achieving control of the hyperprolactinaemia and tumour shrinkage.

A trial of dopamine agonist withdrawal is most likely to be successful if attempted in patients in whom there has been restoration of normal serum prolactin, significant reduction in tumour size on magnetic resonance imaging, low maintenance doses of dopamine agonists, and a treatment duration of at least 2 years.[11][25]

Remission of hyperprolactinaemia in patients with prolactinoma following dopamine agonist withdrawal varies between studies, with greater success in microprolactinomas (approximately 40%) compared to macroprolactinomas (approximately 30%).[25]

Cabergoline is the recommended first-line dopamine agonist due to superior efficacy in normalising serum prolactin and reducing tumour size, better tolerability, and more convenient dosing regimen.[11][13]

Primary options

cabergoline: 0.25 mg orally twice weekly or 0.5 mg orally once weekly initially, increase by 0.5 mg/dose increments every 4 weeks, increase dose gradually until desired reduction in prolactin levels and/or tumour

More

Secondary options

bromocriptine: 1.25 to 2.5 mg/day orally initially, increase by 2.5 mg/day increments every 2-7 days, increase dose gradually until desired reduction in prolactin levels and/or tumour

2nd line – trans-sphenoidal surgery

Back
ONGOING
|
post-menopausal women
|
macroadenomas
2nd line – 

trans-sphenoidal surgery

Trans-sphenoidal surgery may be considered for those who do not tolerate dopamine agonists or whose symptoms are not responding to dopamine agonists.[11][18]

Trans-sphenoidal surgery may be complicated and result in anterior pituitary failure and/or diabetes insipidus requiring permanent hormonal replacement, although this is more likely in cases of large and invasive macroadenomas.

Dopamine agonist therapy may need to be continued following surgery if symptomatic hyperprolactinaemia persists.

3rd line – sellar radiotherapy

Back
ONGOING
|
post-menopausal women
|
macroadenomas
3rd line – 

sellar radiotherapy

Radiotherapy is rarely used and is reserved for situations where medical and surgical treatments have failed, and for the rare cases of malignant prolactinomas.[11]

Both conventional radiotherapy and stereotactic radiotherapy do not achieve more than 20% to 40% prolactin normalisation rate in patients with prolactinomas.[17] Thus, most prolactin-secreting adenomas are radioresistant, and this mode of therapy is not an acceptable primary treatment for prolactinomas.

Pituitary radiotherapy is associated with significant long-term morbidity, including hypopituitarism (up to 50% after 10-20 years), cerebrovascular accidents, optic nerve damage, cognitive deterioration, and secondary radiation-induced brain malignancies.

men

1st line – dopamine agonist

Back
ONGOING
|
men
|
microadenomas or macroadenomas
1st line – 

dopamine agonist

Medical treatment with dopamine agonists is considered the first-line therapy.[11]

Treatment usually starts at low doses to avoid adverse effects, with a gradual dose escalation during the first months with the aim of achieving control of the hyperprolactinaemia and tumour shrinkage.

Cabergoline is the recommended first-line dopamine agonist due to superior efficacy in normalising serum prolactin and reducing tumour size, better tolerability, and more convenient dosing regimen.[11][13]

A trial of dopamine agonist withdrawal is most likely to be successful if attempted in patients in whom there has been restoration of normal serum prolactin, significant reduction in tumour size on magnetic resonance imaging, low maintenance doses of dopamine agonists, and a treatment duration of at least 2 years.[11][25]

Primary options

cabergoline: 0.25 mg orally twice weekly or 0.5 mg orally once weekly initially, increase by 0.5 mg/dose increments every 4 weeks, increase dose gradually until desired reduction in prolactin levels and/or tumour

More

Secondary options

bromocriptine: 1.25 to 2.5 mg/day orally initially, increase by 2.5 mg/day increments every 2-7 days, increase dose gradually until desired reduction in prolactin levels and/or tumour

2nd line – trans-sphenoidal surgery

Back
ONGOING
|
men
|
microadenomas or macroadenomas
2nd line – 

trans-sphenoidal surgery

Trans-sphenoidal surgery may be considered for those who do not tolerate dopamine agonists or whose symptoms are not responding to dopamine agonists.[11][18]

Trans-sphenoidal surgery may be complicated and result in anterior pituitary failure and/or diabetes insipidus requiring permanent hormonal replacement, although this is more likely in cases of large and invasive macroadenomas.

Dopamine agonist therapy may need to be continued following surgery if symptomatic hyperprolactinaemia persists.

3rd line – sellar radiotherapy

Back
ONGOING
|
men
|
microadenomas or macroadenomas
3rd line – 

sellar radiotherapy

Radiotherapy is rarely used and is reserved for situations where medical and surgical treatments have failed, and for the rare cases of malignant prolactinomas.[11]

Both conventional radiotherapy and stereotactic radiotherapy do not achieve more than 20% to 40% prolactin normalisation rate in patients with prolactinomas.[17] Thus, most prolactin-secreting adenomas are radioresistant, and this mode of therapy is not an acceptable primary treatment for prolactinomas.

Pituitary radiotherapy is associated with significant long-term morbidity, including hypopituitarism (up to 50% after 10-20 years), cerebrovascular accidents, optic nerve damage, cognitive deterioration, and secondary radiation-induced brain malignancies.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer