Approach to the pregnant patient with prolactinoma

Prolactinomas account for approximately half of the pituitary adenomas and predominantly affect women of reproductive age. Hyperprolactinemia commonly causes infertility by suppressing hypothalamic gonadotropin-releasing hormone (GnRH) secretion and impairing gonadal function. Because dopamine agonist therapy can rapidly restore fertility, clinicians caring for women with prolactinomas should be qualified to manage problems that may arise during pregnancy. Pregnancy is characterized by physiological enlargement of the anterior pituitary gland and progressive hyperprolactinemia, primarily driven by increased placental estrogen secretion. Therefore, the management of prolactinoma during preconception, pregnancy, and the postpartum period requires an individualized, multidisciplinary approach by an experienced team. The principal challenges are symptomatic tumor enlargement and, rarely, pituitary apoplexy. If clinically significant tumor growth occurs during pregnancy, dopamine agonist therapy can be safely restarted. Both bromocriptine and cabergoline may be used safely during gestation, but cabergoline is increasingly preferred because of its greater efficacy and better tolerability. In patients with pituitary apoplexy, management may include close observation, dopamine agonist therapy, glucocorticoid replacement when indicated, or transsphenoidal surgery, depending on the severity of clinical and neuro-ophthalmological findings. Breastfeeding can generally be permitted in women with prolactinomas; therefore, dopamine agonist therapy should be withheld during lactation unless treatment is clinically necessary. This review discusses the practical aspects of recognizing, and managing prolactinoma-related problems before, during, and after pregnancy.