Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 136

Before ART treatment is commenced, women with hyperprolactinemia should be investigated for known causes, and appropriate treatment to treat any underlying causes and normalize PRL should be undertaken. Where it is thought to be medication‐induced, and if it is possible to do so safely, the medication should be discontinued and PRL repeated 1 week later [11,13].

The primary goal of therapy in patients with hyperprolactinemia is to restore gonadal and sexual function by normalizing PRL levels [13]. If successful, in women of childbearing age fertility is generally restored. Occasionally patients with mild hyperprolactinemia with regular menses who wish to become pregnant may require treatment [13]. If following successful treatment fertility is not restored, ovulation induction with antiestrogens or gonadotropins can be attempted.

The mainstay of treatment of hyperprolactinemia is treatment or removal of the underlying cause. Where it is thought to be medication‐induced, some guidelines suggest discontinuation of the medication for 3 days or substitution of an alternative drug after consulting the patient's physician, followed by repeat measurement of serum prolactin [1]. However, this is based on low quality evidence, and particularly for antipsychotic medication other guidelines do not endorse this course of action [20].

First line treatment of prolactinomas is dopamine agonist therapy, with surgery traditionally reserved for the few patients who are resistant or intolerant to medication or have predominantly cystic tumors [1,13]. There are however calls for the indications for surgical treatment of prolactinomas to be widened [21]. Most tumors shrink quickly following initiation of dopamine agonist therapy, with normalization of PRL levels. Bromocriptine is well established as a safe and effective therapy for hyperprolactinemia. However, up to 12 % of patients are unable to tolerate it due to adverse events which include nausea and dizziness, and 25% are resistant to it [1,22]. Cabergoline is better tolerated than bromocriptine but is not licensed for treatment of hyperprolactinemia to induce pregnancy. There is, however, no evidence that either is associated with adverse maternal–fetal outcomes [23]. An association has been demonstrated between ergot‐derived dopamine agonist use and valvular heart disease in patients treated for Parkinson's disease, mainly when daily doses are above 3 mg [24]; more recently concern has been raised among endocrinologists about the safety of long‐term treatment with drugs like bromocriptine and cabergoline in hyperprolactinemic patients [25]. Although most reports do not show an association between use of dopamine agonists and clinically relevant valvulopathy in this patient group, regulatory bodies worldwide are now recommending regular monitoring with echocardiography [26]. Quinagolide is a non‐ergot‐derived agent which is unlikely to cause this side effect and has been used successfully in the management of prolactinomas [22]. Further potential side effects of dopamine agonists include psychological disturbances, either de novo or as exacerbations of prior psychiatric disease. Patients with hyperprolactinemia treated with dopamine agonists need to be warned about and monitored for changes in mood and behavior, impulse control disorders, depression, mania and other types of psychosis [27].