Hyperprolactinemia: Pitfalls in diagnosis and management
Abstract
Hyperprolactinemia is one of the most frequent endocrine abnormalities encountered in clinical practice, yet an elevated serum prolactin value is too often equated with a prolactinoma. This shortcut leads to unnecessary pituitary imaging, prolonged dopamine agonist therapy, and occasionally, missed diagnoses of serious sellar disease. This presentation will examine the common and less-recognised pitfalls in evaluating and treating hyperprolactinemia, drawing on current guidance and our clinical experience at Dhaka Medical College Hospital. On the diagnostic side, the discussion will cover physiological and stress-related elevations, the frequent contribution of medications such as antipsychotics, metoclopramide and domperidone, and secondary causes including primary hypothyroidism, chronic kidney disease and liver cirrhosis. Laboratory traps will be highlighted: macroprolactinemia, which can be identified by polyethylene glycol precipitation; the 'hook effect', which may produce misleadingly modest values in giant prolactinomas unless the serum is diluted; and inconsistencies in assay units. The distinction between a true prolactinoma and pituitary stalk compression by a non-functioning macroadenoma, and the risk of over-interpreting incidental pituitary lesions on magnetic resonance imaging (MRI), will also be addressed. Management pitfalls include treating asymptomatic macroprolactinemia, starting dopamine agonists for antipsychotic-induced hyperprolactinemia without psychiatric liaison, mislabelling non-adherence or inadequate dosing as dopamine agonist resistance, overlooking impulse control disorders and cardiac valvular concerns with cabergoline, premature or poorly monitored drug withdrawal, and inadequate planning for pregnancy in women with macroprolactinomas. Choices will also be discussed in the light of drug availability and cost in Bangladesh. The practical message is that every elevated prolactin value deserves confirmation and clinical context before a diagnostic label or long-term treatment is applied. [J Assoc Clin Endocrinol Diabetol Bangladesh, 2026;5(Suppl 1): S8]