Prolactin and subfertility

A high prolactin (PRL) is a common finding in a fertility practice.  I first wrote to this topic a year ago in another website and thought to repost it here may be helpful.  I haven’t made any changes.

Reasons for an elevated PRL level

The most common reasons for an apparently elevated PRL in a fertility practice are as follows:

Stress
Exercise
Antidepressants
Macroprolactin
Prolactin-secreting pituitary adenoma
Fickle assay (our tests can be wrong).

(These are the common reasons. For a complete list, you could go here.).

What to do when PRL is high

With so many variables, the first thing we suggest with a high PRL is to repeat the test. We like to do the repeat test in the morning if possible.

Though a high PRL can be associated with an adenoma as mentioned above, it is only when the PRL level is >100 on two occasions do we order an MRI. (Yes, I will order an MRI when PRLs are <100, but on a case-by-case basis). Usually the repeated blood test is all that is necessary.

If you google this topic, you will find that high PRL is associated with galactorrhea (discharge from the nipples) and vision changes. But most subfertile women with high PRL won’t have these findings.

Some women with high PRL will have irregular cycles, but again, not all.

Nonetheless, when PRL is >20 twice in a row, and other explanations have been ruled out, we need to contemplate treatment.

Why we “need” to contemplate treatment

Elevated PRL may compromise implantation. And, subfertility is such a complicated business, we hate to see anything outside of the normal range that could potentially cause a problem. So, we tend to treat everybody.

The standard intervention is bromocryptine 2.5mg/d

Unfortunately, side effects include GI distress…which is a very common complaint. The symptoms dissispate for most women after 3 weeks or so.

But they do not dissipate for everyone. If you are having difficulty, ask your doctor about taking the medication vaginally instead of orally. You could ask after cabergoline, which has fewer side effects…but as a newer medication, we cannot promise the same safety profile

Once you are pregnant

Once pregnant, most –but not all– women are asked to stop their bromocryptine. It can be difficult for clinics to remember who is taking bromo and who isn’t, so once YOU are pregnant, ask your doctor to reassess your need for the medication.

Yours,

Tom Hannam

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