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endo.prolactinoma.core.v1

Prolactinoma and hyperprolactinemia

endocrinologychronicadultoutpatientinpatient
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Prolactinoma / hyperprolactinemia dossier — hyperprolactinemia is a finding, not a diagnosis: exclude physiologic / drug / hypothyroid / renal-hepatic / macroprolactin / HOOK effect / stalk effect BEFORE labelling a prolactinoma. Sex-specific: women present early with oligo/amenorrhoea + galactorrhoea + infertility (microadenoma typical); men present late with hypogonadism/ED and often a macroadenoma with mass effect/visual loss. Dopamine agonist (cabergoline preferred; bromocriptine if pregnancy planned) is first-line for symptomatic prolactinoma — normalises PRL, restores gonadal axis, shrinks micro AND macro tumour. Surgery for DA resistance/intolerance, CSF leak, apoplexy, or patient choice. Key sibling pivot: a macroadenoma with only mildly elevated PRL is stalk effect (route to hypopituitarism) until hook-effect dilution + DA trial prove a true prolactinoma; co-secreting mammosomatotroph overlaps acromegaly (check IGF-1). Manifest is a PLACEHOLDER (prisma/seed/manifests/endo.cushing_syndrome.v1.ts) — no dedicated prolactinoma manifest yet. No rxcui assigned anywhere (RxNav validation deferred). Bayesian likelihood ratios for PRL thresholds deferred. No prolactinoma-specific calculator in registry — generic calc.news2 / calc.qsofa mapped for acute-illness severity only.

Entry points (5)

  • symptom
    Woman: galactorrhoea + oligo/amenorrhoea + infertility (Endo Soc 2011)
    galactorrhea_oligomenorrhea_infertility
  • symptom
    Man: low libido / ED / infertility / gynecomastia (Pituitary Soc 2023)
    hypogonadism_low_libido_ed
  • lab_abnormality
    Incidental / screening elevated serum prolactin (Endo Soc 2011)
    elevated_serum_prolactin
  • imaging
    Incidental sellar mass on MRI/CT (pituitary incidentaloma) (Pituitary Soc 2023)
    incidental_sellar_mass
  • symptom
    Bitemporal hemianopia / headache / ophthalmoplegia from macroadenoma (Pituitary Soc 2023)
    visual_field_loss_headache

Required inputs (14)

  • sexrequired
    demographic • used at CONTEXT
    Presentation and tumour-size distribution differ markedly by sex (women micro/early; men macro/late)
  • agerequired
    demographic • used at CONTEXT
    Premenopausal vs postmenopausal changes symptom salience and treatment goals; reproductive intent
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Pregnancy is the leading physiologic cause AND drives DA choice/continuation (bromocriptine if conception planned)
  • serum_prolactinrequired
    lab • used at INITIAL_WORKUP
    Core analyte; magnitude triages stalk effect vs micro vs macroprolactinoma (>250 ng/mL favours macroprolactinoma)
  • serum_prolactin_diluted
    lab • used at BRANCHING_WORKUP
    Hook-effect exclusion — 1:100 serial dilution when large sellar mass with only mild PRL elevation
  • macroprolactin_peg
    lab • used at BRANCHING_WORKUP
    PEG precipitation / macroprolactin screen when high PRL but asymptomatic (assay artifact)
  • tsh_ft4required
    lab • used at INITIAL_WORKUP
    Primary hypothyroidism raises TRH → PRL; reversible secondary cause to exclude before imaging
  • beta_hcgrequired
    lab • used at INITIAL_WORKUP
    Pregnancy — the single most common physiologic cause; exclude first in any reproductive-age woman
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    CKD reduces PRL clearance (systemic cause); also informs MRI contrast safety
  • lft
    lab • used at INITIAL_WORKUP
    Cirrhosis is a systemic cause of mild hyperprolactinemia
  • gonadal_axis_panelrequired
    lab • used at INITIAL_WORKUP
    LH/FSH/estradiol/testosterone — confirm hypogonadism and gauge bone-loss risk if untreated
  • current_medsrequired
    medication • used at CONTEXT
    Antipsychotics (risperidone/paliperidone), metoclopramide, SSRIs, verapamil, opioids, estrogens — the cardinal pharmacologic exclusion
  • pituitary_mri
    imaging • used at BRANCHING_WORKUP
    Dedicated sellar MRI defines micro (<10 mm) vs macroadenoma and mass effect once secondary causes excluded
  • formal_visual_fields
    imaging • used at BRANCHING_WORKUP
    Macroadenoma abutting/compressing chiasm requires formal perimetry (bitemporal hemianopia)

12-phase flow (12)

  1. 1FRAME
    Hyperprolactinemia is a finding, not a diagnosis: exclude physiologic / drug / hypothyroid / renal-hepatic / macroprolactin / hook BEFORE naming a prolactinoma (Endo Soc 2011)
    inputs: sex, serum_prolactin
    advance: Confirmed true hyperprolactinemia framed against the exclusion ladder
  2. 2ENTRY
    Woman with galactorrhoea/oligo-amenorrhoea/infertility; man with hypogonadism/ED; incidental high PRL; incidental sellar mass; visual loss/headache (Endo Soc 2011; Pituitary Soc 2023)
    inputs: sex, age
    advance: Engine entered via a recognised trigger
  3. 3CONTEXT
    Capture sex, age/menopausal status, reproductive intent, pregnancy/lactation, full medication review (antipsychotic/prokinetic/SSRI/verapamil/opioid/estrogen), chest-wall lesions, CKD/cirrhosis (Endo Soc 2011)
    inputs: sex, age, pregnancy_status, current_meds
    advance: Physiologic + pharmacologic + systemic context fully captured
  4. 4RED_FLAGS
    Macroadenoma with acute severe headache + visual loss + ophthalmoplegia = pituitary apoplexy (acute hypopituitarism — STAT hydrocortisone, MRI, neurosurgery); rapidly progressive visual field loss; CSF rhinorrhoea on DA-induced tumour shrinkage (Pituitary Soc 2023)
    inputs: serum_prolactin, formal_visual_fields
    actions: workup.pituitary_apoplexy, calc.news2
    advance: Apoplexy / acute visual compromise / CSF leak screened and escalated if present
  5. 5INITIAL_WORKUP
    Confirm with a single resting (non-stressed) serum PRL; β-hCG, TSH/FT4, creatinine/eGFR, LFT, gonadal axis (LH/FSH/estradiol or testosterone); medication reconciliation drives drug-induced exclusion (Endo Soc 2011)
    inputs: serum_prolactin, beta_hcg, tsh_ft4, creatinine_egfr, gonadal_axis_panel
    actions: panel.hormone, panel.thyroid, panel.metabolic, workup.amenorrhea
    advance: Secondary/physiologic causes excluded and true hyperprolactinemia confirmed
  6. 6BRANCHING_WORKUP
    Asymptomatic high PRL → macroprolactin (PEG) screen; large sellar mass with mild PRL → 1:100 dilution for HOOK EFFECT; true hyperprolactinemia after exclusions → dedicated pituitary MRI; macroadenoma → formal visual fields + full anterior pituitary axis (stalk-effect hypopituitarism) (Endo Soc 2011; Pituitary Soc 2023)
    inputs: serum_prolactin_diluted, macroprolactin_peg, pituitary_mri, formal_visual_fields
    actions: workup.hypopituitarism, workup.gynecomastia, workup.erectile_dysfunction, panel.hormone
    advance: Macroprolactin/hook resolved; MRI obtained; tumour sized; pituitary axis assessed
  7. 7DIFFERENTIAL
    Microprolactinoma vs macroprolactinoma vs stalk-effect mild hyperprolactinemia from a non-lactotroph mass (NFPA, craniopharyngioma, meningioma, metastasis) vs drug-induced vs primary hypothyroidism vs macroprolactin artifact vs idiopathic; co-secreting somatomammotroph (acromegaly + hyperprolactinemia)
    inputs: serum_prolactin, pituitary_mri
    advance: Terminal diagnosis assigned (PRL magnitude + MRI is the decisive pivot)
  8. 8RISK_STRATIFICATION
    Tumour size (micro vs macro) and proximity to chiasm; symptom burden (hypogonadism, infertility, bone loss); PRL magnitude; apoplexy risk for macroadenoma; reproductive plans; deferred general illness severity scoring if acutely unwell (Pituitary Soc 2023)
    inputs: serum_prolactin, pituitary_mri
    actions: calc.news2
    advance: Size/symptom/reproductive tier documented and treatment goal set
  9. 9TREATMENT
    Exclude/treat secondary causes first (stop offending drug if safe; treat hypothyroidism). Symptomatic prolactinoma → dopamine agonist first-line: cabergoline 0.25–0.5 mg twice weekly titrated (preferred — efficacy/tolerability, shrinks micro & macro), bromocriptine if pregnancy planned. Titrate to PRL normalisation + gonadal recovery + tumour shrinkage. Transsphenoidal surgery for DA resistance/intolerance, CSF leak, apoplexy, or patient choice. Pregnancy: stop DA after conception in micro, individualise in macro. Estrogen / bone protection if untreated (Endo Soc 2011; Pituitary Soc 2023)
    inputs: serum_prolactin, pregnancy_status, pituitary_mri
    advance: DA initiated/secondary cause treated, or surgery/observation plan documented
  10. 10DISPOSITION
    Outpatient endocrinology for almost all; admit for apoplexy, acute visual loss, CSF leak, or severe DA psychiatric/impulse-control crisis; neurosurgery referral for surgical candidates (Pituitary Soc 2023)
    advance: Setting and specialty referrals secured
  11. 11MONITORING
    Serum PRL ~1 month after dose change then periodically; MRI at ~1 year (sooner for macro / new symptoms / non-response); formal visual fields for macroadenoma; echocardiography if high cumulative cabergoline dose; DEXA if untreated/hypogonadal; psychiatric/impulse-control screening on DA (Endo Soc 2011; Pituitary Soc 2023)
    inputs: serum_prolactin, pituitary_mri
    actions: panel.hormone, panel.cardiac
    advance: Monitoring schedule individualised by tumour size and DA dose
  12. 12FOLLOWUP
    Endocrinology long-term; consider DA taper/withdrawal trial after ≥2 years of normoprolactinemia + marked tumour shrinkage with surveillance; preconception counselling; bone health; symptom/return precautions (visual change, severe headache, galactorrhoea recurrence) (Endo Soc 2011; Pituitary Soc 2023)
    advance: Long-term surveillance + withdrawal/pregnancy plan booked