Sunday, January 10, 2016

Diagnosis & The Endocrinologist

On Wednesday, we met with the reproductive endocrinologist for the first time. Our local clinic is one of the Boston IVF clinics (Here's a link to all of their clinic locations across the U.S.). My gynecologist actually dealt with infertility herself and referred me to the same endocrinologist she personally worked with. We are not actually classified as dealing with "infertility," as that requires six months of trying without conceiving to be diagnosed. This actually works to our advantage in this instance for billing purposes, as insurance will cover treatment for hyperprolactinemia but not infertility. I knew this, which is why I wanted a diagnosis and treatment before those magic 6 months passed. 

Prior to our appointment, we had a long list of information to complete online. Known family history of genetic abnormalities, infertility, multiple miscarriages, etc., as well as a laundry list of possible health conditions for both of us. The very good news is that we have no other known health conditions. We've both had blood work in the last three months and received a clean bill of health. Thyroids functioning normally (very good news on both fronts for conceiving) and no signs of chronic health conditions.

Confirmation of Prolactinoma
As my gynecologist had initially suspected, I have a microprolactinoma. Also called a pituitary adenoma, this is a small, benign tumor (mine is 5mm, anything 10mm or below is considered "micro") on the pituitary gland that secretes excess prolactin. The great news is that it is not a macroadenoma, which may have required surgery. I found the above image in a Google search to show how close the pituitary glad is located to the optic chiasm. In the case of a macroadenoma, it can press on the optic chiasm and cause visual disturbances. We are very happy this is not the case! 

We are not sure how long I have had a prolactinoma, as my cycles have always been irregular whenever I was not taking birth control. I may have been born with it, or may have had it since I first started menstruating as a young teenager. 

While this benign tumor is not likely to cause major health issues, the excess prolactin will negatively impact my ability to ovulate every month. Although this does not mean every cycle is anovulatory (a cycle in which the ovaries fail to release an egg), there is a good likelihood that I'm at least not ovulating some of the time. Without treating the prolactinoma, my cycles would remain irregular and it would likely take an extended period of time to successfully conceive. 

Treatment Planning
In treating a prolactinoma, there are two medication options to shrink the tumor and limit its release of excess prolactin. The older medicine is bromocriptine (Parlodel) and would be taken daily. Bromocriptine has a high incidence of adverse side effects (78% of patients) in the variety of nausea, headaches, dizziness and vomiting. Additionally, the research suggests it is at least somewhat less effective than a newer drug available.

The other option, cabergoline (Dostinex), is better tolerated than bromocriptine (68% of women reported adverse effects) and the pill only needs to be taken twice weekly (Source). Collaboratively, we agreed that cabergoline was the drug of choice. The only downside is that cabergoline is more expensive. Although the cost per pill is significantly higher, the overall monthly cost is hardly noticeable -- $20 more per month for cabergoline. I'm willing to pay that difference to have a more effective and better-tolerated medication!

Here's a comparison of how each of these medications treats the excess level of prolactin:

A quick glance at this chart shows cabergoline would be expected to quickly drop my serum prolactin level within 4 weeks. Once my prolactin level dropped below 20, we would anticipate it would also be much more likely that I would ovulate every month. 

I will begin my treatment with cabergoline next week and will plan to chronicle my progress here. I will also have a follow-up MRI in 6 months to determine if the cabergoline successfully shrunk the prolactinoma. I really like the endocrinologist we were referred to, and will create a separate post of what else the endocrinologist recommended outside of treating my prolactinoma. 



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