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Hyperprolactinaemia

Checked: 23-08-2021 by Vicky Ryan Next Review: 23-08-2022

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Definition

An elevated serum prolactin which may be physiologically, pathologically or pharmacologically induced

Important points

May be asymptomatic but untreated, can result in galactorrhoea, infertility, hypogonadism and accelerated bone loss

A single measurement ≥ 700 mu/L usually confirms the diagnosis, as long as the serum sample was obtained with minimal venepuncture stress.

Who to refer

Patients with hyperprolactinaemia should be referred routinely to endocrinology via eRS.

Medication induced hyperprolactinaemia

For likely medication induced symptomatic hyperprolactinaemia, stop the medication for 3 days OR switch to a mediation with lower dopamine antagonist potency e.g. aripiprazole (discuss with the patient’s team e.g. Psychiatry)

Re-measure the prolactin after 3 days
If the drug cannot be stopped, the raised prolactin doesn’t coincide with starting the medication OR the prolactin remains raised despite 3 days off medication, investigate and refer.

See the Psychotropic Medication Monitoring page for further details on antipsychotics and prolactin.

Red Flags

Urgent referral via eRS in the following cases:

Visual field abnormalities
Prolactin >5000mU/L – likely to represent a macroprolactinoma
9am cortisol < 100nmolL or symptoms suggestive of acute adrenal insufficiency (see separate adrenal insufficiency guidance).

Before referral

Take a full history and clinical examination of the following:

Symptoms of hyperprolactinaemia – galactorrhoea, amenorrhoea, symptoms of hypogonadism/erectile dysfunction
Chance of pregnancy/any breast feeding
Headache history
Visual field assessment – looking predominantly for peripheral visual field abnormalities
Other signs and symptoms suggestive of concurrent pituitary hormone excess, particularly:
- Acromegaly - frontal bossing, increased shoe size, macroglossia and macrognathia
- Cushing’s disease - central adiposity, proximal myopathy, striae, easy bruising
Possible medications causing a raised prolactin and their indication/long term need (may need discussion with other professions e.g. Psychiatry)
- Anti-psychotics e.g. phenothiazines, haloperidol, risperidone, fluoxetine, monoamine oxidase inhibitors
- Anti-emetics e.g. metoclopramide, domperidone
- Anti-convulsants
- Oestrogens including withdrawal of the contraceptive pill
- Opiates
- Verapamil

Re-measure the prolactin after 3 days
If the drug cannot be stopped, the raised prolactin doesn’t coincide with starting the medication OR the prolactin remains raised despite 3 days off medication, investigate and refer as below

Further investigations

Pregnancy test – ensure this is done prior to referral.
U&Es – renal failure causes enhanced production and decreased clearance of prolactin.
Pituitary panel – 9am cortisol, LH, FSH, oestradiol/testosterone, IGF-1, TSH and free T4.

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References:

(1) https://academic.oup.com/jcem/article/96/2/273/2709487

(2) https://patient.info/doctor/hyperprolactinaemia-and-prolactinoma

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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