A 27-year-old man present with complaints of loss of libido and erectile dysfunction since a year. On questioning, he gives history of headache, dull aching, global, not associated with nausea or vomiting, usually relieved by painkillers, present on 5 days a week. He has also noticed that sometimes he bumped into objects on his sides while walking. He has also noticed constipation and weight gain. On examination, he is 160 cm tall with a BMI 25 kg/m2. Blood pressure 110/70 mm of Hg, no postural drop. Confrontation test reveals bilateral temporal hemianopia. Testicular volume 15 mL soft bilateral. No galactorrhea is elicited. Ankle jerks delayed. Laboratory investigations are as follows: Hemoglobin 10.5 g/dL, normocytic normochromic anemia. Testosterone 100 ng/dL, LH 0.01 IU/L, FSH 0.01 IU/L, TSH 2 microIU/L, free T4 0.68 ng/dL. Cortisol 2.8 mg/dL. Prolactin 47 ng/mL from one lab and 1780 ng/mL from another lab. Automated perimetry reveal bitemporal hemianopia. Magnetic resonance imaging of the hypothalamic pituitary region reveals 2.4 cm tall, pituitary mass with suprasellar extension with compression of the optic chiasm without parasellar extension. A diagnosis of pituitary macroadenoma probably macroprolactinoma with hypopituitarism is made.
What are the treatment options available to the patient is unable to tolerate or is unresponsive to dopamine agonists?
Medicine
The first step is to increase dose of dopamine agonists. Cabergoline is found to be effective in patients resistant to bromocriptine. Trans-sphenoidal surgery is an option for patient who are symptomatic and are unresponsive to dopamine agonists. For patients who fail surgical treatment, radiation therapy is an option although the lag period can run into years to see the effects.
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