Hyperprolactinaemia: prolactinoma diagnosis (macroprolactin, MRI pituitary), cabergoline management, pregnancy considerations

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Target exams

Red flags

• Acute severe headache with visual loss, ophthalmoplegia, and altered consciousness in a known or new pituitary adenoma — pituitary apoplexy; urgent MRI, hydrocortisone 100 to 200 mg IV bolus before imaging, neurosurgical decompression if vision or neurology deteriorates
• Bitemporal hemianopia on confrontation with secondary amenorrhoea and a prolactin over 250 micrograms per litre — macroprolactinoma with chiasmal compression; start cabergoline urgently, arrange pituitary surgery input, urgent MRI with gadolinium
• Pregnant woman with a known macroprolactinoma — monthly clinical review with visual field evaluation every 3 months; MRI pituitary without gadolinium if growth suspected; maintenance dopamine agonist therapy is an option for large macroprolactinomas; do not stop dopamine agonist without review
• Pituitary mass with a disproportionately low prolactin for its size (under the 200 ng/mL prolactinoma threshold) — likely stalk effect from a non-functioning adenoma, NOT a true prolactinoma; treatment is surgery, NOT escalating dopamine agonist (which would mask tumour growth)
• Patient on an antipsychotic (risperidone, amisulpride, haloperidol) with new amenorrhoea and galactorrhoea — drug-induced hyperprolactinaemia; review with psychiatry before imaging; consider switching to a prolactin-sparing agent (aripiprazole is the consensus-named choice)
• Hyperprolactinaemia in pregnancy with new visual symptoms — do NOT assume physiological; MRI without gadolinium; consider delivery if vision threatened