A 32-year-old woman has irregular periods, galactorrhoea and elevated prolactin. How would you approach this?

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Accepted Answer

This suggests hyperprolactinaemia. Firstly I would confirm with a repeat fasting prolactin sample as levels can be transiently elevated by stress or venepuncture. Secondly I would exclude physiological causes — particularly pregnancy with a pregnancy test — and review medication history carefully (antipsychotics, antidepressants, metoclopramide). I would always check TSH because hypothyroidism can elevate prolactin. If prolactin remains elevated with no reversible cause, I would arrange an MRI pituitary. I would assess for mass-effect symptoms — headaches, visual disturbance — and arrange visual field testing if a macroadenoma is suspected. Management depends on cause: for prolactinomas first-line is a dopamine agonist such as cabergoline; surgery is reserved for resistance or significant mass effect. Levels above about 5000 mIU/L strongly suggest a macroprolactinoma, particularly with amenorrhoea or visual disturbance; lower elevations are more often due to medications, stress, hypothyroidism or stalk effect.

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