Endocrine Abstracts

Background: Prolactinomas are the most common functioning pituitary adenomas and are mostly diagnosed in fertile women. Dopamine-agonists (DAs) have always represented the cornerstone of prolactinoma treatment in terms of hormonal control and tumor shrinkage. Recent guidelines suggest surgery as an alternative option in selected cases after a joint evaluation with an expert surgeon. Prolactinoma management in women seeking fertility and during pregnancy remains challenging, and areas of uncertainty are still present, especially concerning drug safety. The management should be personalized. Herein, we present the results of a cross-sectional survey conducted among Italian endocrinologists, focusing on managing prolactinomas in fertile women and during pregnancy.

Methods: Italian Association of Clinical Endocrinologists members were invited to participate in an online anonymous survey. 578 responded to the survey (61% women, equal distribution between 30-50 and 50-70 years of age).

Results: 88% of responders declare to be acquainted with prolactinoma management, and they almost systematically provide counseling on fertility and pregnancy to women of reproductive age. The choice of first-line therapy (DAs vs surgery) is influenced by pregnancy desire (80%) and adenoma size (84%). In particular, 34% of participants opt for surgery in macroadenomas, 22% discuss the choice with the patient in microadenomas, and 77% prefer medical therapy in microadenomas. In women under medical therapy and seeking pregnancy, most clinicians continue the ongoing DAs; 22% switch from cabergoline to bromocriptine, while 18% discontinue therapy. Once pregnancy is confirmed, 58% of participants may continue DAs in selected cases. Great heterogeneity can be observed in prolactinoma management during pregnancy: according to 25% of respondents, women need clinical follow-up. Conversely, nearly 20% require visual field testing only in case of new-onset visual impairment. More than half of responders require prolactin measurement during pregnancy. Finally, 39% advise against vaginal delivery in macroprolactinomas, but the majority do not generally discourage breastfeeding. After delivery and breastfeeding, only half of the participants systematically reassess prolactin concentrations and repeat magnetic resonance imaging before restarting DAs.

Conclusion: Prolactinoma management in fertile-age women is still a challenge in clinical practice. Clinical, hormonal, and ophthalmological follow-ups are largely heterogeneous among endocrinologists. Moreover, a lack of compliance with current guidelines emerged concerning DAs therapy in women seeking fertility and during pregnancy, indications for delivery modalities, and the need for prolactin re-evaluation before restarting DAs. An effort is required from endocrinological societies to spread knowledge about prolactinomas in reproductive-age women and promote management uniformity among endocrinologists.