Hyperprolactinemia: Symptoms, Causes & Treatment

Hyperprolactinemia is a medical condition characterized by elevated levels of prolactin hormone in the blood above normal range. Prolactin is produced by the anterior pituitary gland and plays a vital role in regulating lactation, reproductive processes, and endocrine functions. When this hormone rises abnormally, it causes menstrual irregularities in women and erectile dysfunction and infertility in men, along with various other symptoms.

Prolactinoma, a benign tumor of the pituitary gland, is the most common cause of hyperprolactinemia, accounting for 40-50% of cases. Other causes include certain medications, liver disease, hypothyroidism, and pregnancy. This condition affects various age groups but is more common in women of reproductive age. In Jordan and the Arab region, accurate prevalence statistics are limited, but diagnosis has become easier with the availability of laboratory tests and medical imaging.

The good news is that elevated prolactin is a treatable condition, either through oral medications (such as cabergoline and bromocriptine) or surgery in cases that do not respond to medical treatment. Managing this condition requires regular follow-up with an endocrinologist to ensure symptom control and long-term stability.

Symptoms of hyperprolactinemia are diverse and vary depending on the degree of elevation and duration. Symptoms may appear gradually and the patient may not notice them initially. It is important to distinguish between symptoms in women and men, as each group has its own characteristics. In some cases, the condition is asymptomatic and is discovered incidentally during routine screening.

• In women: Menstrual irregularities (absent or intermittent periods - Amenorrhea), infrequent menstruation (Oligomenorrhea), abnormal uterine bleeding.
• Breast milk discharge without pregnancy or nursing: May occur spontaneously or with breast pressure (Galactorrhea).
• Breast pain or swelling: May accompany discharge or occur independently.
• Decreased sexual desire (Decreased Libido): Occurs in both women and men.
• In men: Erectile dysfunction: One of the most common symptoms in males.
• Decreased sexual desire and infertility in men: Reduced sperm count and poor motility.
• Persistent headaches: Especially if caused by a large prolactinoma tumor that may create pressure.
• Vision problems: May include blurred vision or loss of part of the visual field if the tumor pressures the optic nerve.
• Hot flushes and night sweats: Due to hormonal imbalance.
• Weight gain: May occur due to effects on energy metabolism and appetite.
• Vaginal dryness in women: Resulting from decreased estrogen levels.
• Depression and anxiety: May accompany the condition as secondary symptoms.

• Prolactinoma: A benign pituitary gland tumor that produces excess prolactin, representing the primary cause of hyperprolactinemia and may be associated with symptoms of pressure on surrounding tissues such as headaches.
• Medications: Certain drugs increase prolactin, including antipsychotics (haloperidol, clozapine), selective serotonin reuptake inhibitors (SSRIs), anti-nausea medications (metoclopramide), and blood pressure medications like verapamil and reserpine.
• Hypothyroidism: When thyroid hormone levels decrease, there is a reverse effect on the pituitary gland, raising prolactin.
• Chronic liver disease: The liver plays a role in prolactin metabolism; liver failure or cirrhosis leads to its elevation.
• Chronic kidney failure: The kidneys help filter prolactin from the blood; kidney failure causes its accumulation.
• Pregnancy and breastfeeding: A natural and temporary elevation of prolactin occurs during pregnancy and breastfeeding.
• Chest wall stimulation: Overly tight clothing or infection (such as herpes) may stimulate nerve fibers and raise prolactin.
• Chronic stress and emotional distress: Emotional and psychological stress may affect prolactin secretion from the pituitary gland.

• Female sex: Women are more susceptible to hyperprolactinemia than men, especially during reproductive years.
• Age (25-50 years): Elevated prolactin is more common in this age group.
• Use of psychiatric medications: Patients taking antipsychotics or antidepressants are at higher risk.
• Previous endocrine disorders: History of hypothyroidism or diabetes increases the risk.
• Chronic liver and kidney disease: Patients with hepatic or renal failure are at higher risk.
• Pregnancy and breastfeeding: Pregnant and nursing women experience a natural elevation in prolactin.
• Family history: Presence of pituitary tumors in the family may increase genetic risk.
• Autoimmune dysfunction: Some autoimmune diseases may be associated with elevated prolactin.
• Severe obesity: May affect hormonal balance and increase prolactin.
• Chronic psychological stress: Continuous stress increases the likelihood of the condition.

Diagnosis of hyperprolactinemia depends on a combination of clinical, laboratory, and imaging tests. Diagnosis begins with a detailed medical history and comprehensive physical examination, then is confirmed by laboratory tests. The goal is not only to confirm the diagnosis but also to identify the cause and check for any complications.

• Serum Prolactin Test: Normal values for women: less than 25 ng/mL (or less than 25 IU/L), and for men: less than 17 ng/mL. Elevated values confirm the diagnosis. Blood should be drawn in the morning on an empty stomach for accurate results.
• Thyroid Function Tests (TSH and T4): To detect hypothyroidism which may be the cause.
• Liver and Kidney Function Tests: To exclude liver and kidney disease as a cause.
• Brain MRI: The most important imaging test to diagnose prolactinoma and determine its size and extent. CT imaging is used as an alternative if the patient cannot undergo MRI.
• Visual Field Testing: If the tumor is large enough to compress nerves and eyes.
• Other Hormone Measurements: Such as growth hormone (GH) and cortisol to assess other pituitary functions.
• Dynamic Tests (Suppression Tests): In some complex cases, advanced tests may be performed to assess pituitary reserve.

Medications

• Cabergoline: The first-line medication option and most effective and safe. It works by inhibiting prolactin secretion from the pituitary gland. Taken orally once or twice weekly. Has fewer side effects than bromocriptine.
• Bromocriptine: An older but effective drug, taken daily. May cause more side effects such as dizziness and nausea.
• Dihydroergotamine: Another option but used in rare cases and when cabergoline fails.

Procedures and Surgery

• Pituitary Surgery (Transsphenoidal Surgery): Performed when the tumor is large and causes pressure on surrounding tissues or when it does not respond to medications. The surgeon accesses the tumor through the nose and nasal sinuses without directly opening the skull, making it less invasive.
• Regular MRI Monitoring: For small tumors that do not cause symptoms, monitoring may be recommended instead of immediate treatment, with periodic check-ups.

Lifestyle Changes

• Avoid prolactin triggers: Avoid medications that increase prolactin (if they can be changed in consultation with your doctor).
• Stress management: Practice relaxation techniques, mindfulness, and regular exercise.
• Wear comfortable clothing: Avoid very tight clothing, especially around the chest.
• Treat hypothyroidism: If the cause is hypothyroidism, treating this condition with thyroxine hormone may lower prolactin.
• Maintain a healthy weight: Losing excess weight may help improve hormonal balance.
• Avoid local triggers: Avoid repeated touching or rubbing of the breast or wearing tight underwear that may stimulate the breast.

• Infertility and sexual dysfunction: Elevated prolactin suppresses gonadotropin secretion, reducing sexual desire and fertility. Conception may take longer or may be impossible if the condition is not treated.
• Osteoporosis: Elevated prolactin suppresses estrogen and testosterone secretion, leading to loss of bone mineral density and increased fracture risk.
• Complications of large pituitary tumor: If caused by a large tumor, it may compress nerves around the eyes causing permanent vision loss or other brain tissues.
• Tremor and insomnia: May occur as long-term complications due to persistent hormonal imbalance.
• Depression and psychiatric disorders: Long-term hormonal imbalances may affect mental health and increase the risk of depression and anxiety.
• High blood pressure: Some patients may develop high blood pressure as a secondary complication.
• Brain hemorrhage (Apoplexy): Very rare but bleeding inside a prolactinoma may occur, which is a medical emergency.

• Regular medication review: If you take medications that may increase prolactin (such as antipsychotics), consult your doctor about safe alternatives and get periodic prolactin level checks.
• Treat endocrine disorders: Maintaining good control of thyroid, kidney, and liver health helps prevent secondary hyperprolactinemia.
• Periodic screening: If you have a family history of pituitary tumors, periodic screening may be important.
• Stress management: Practicing relaxation techniques and mindfulness may reduce stress effects on hormones.
• Maintain a healthy weight: Balanced nutrition and regular physical activity help prevent hormonal imbalances.
• Avoid harmful habits: Avoid excessive breast stimulation and wear comfortable, non-tight clothing.
• Regular medical check-ups: Periodic follow-up with an endocrinologist for early detection of any prolactin elevation.
• Consult before new medications: Always consult your doctor before taking any new medication that may affect hormone levels.