A 32-year-old woman presents with galactorrhoea, oligo-amenorrhoea, and prolactin 340 ng/mL. MRI shows an 18 mm pituitary macroadenoma. Visual field testing reveals bitemporal hemianopia. She desires fertility. What is the most appropriate initial management?

• A Cabergoline as first-line medical therapy ✓
• B Transsphenoidal surgery followed by cabergoline
• C Bromocriptine alone due to better safety in pregnancy
• D Pituitary irradiation to debulk tumour before medical therapy

Explanation

Dopamine agonists, particularly cabergoline, are first-line even for macroprolactinomas with visual field defects because they shrink most tumours within weeks to months; visual improvement typically precedes MRI-confirmed shrinkage. Cabergoline has superior efficacy and tolerability over bromocriptine and achieves normalisation in ~80% of macroprolactinomas. Surgery is reserved for dopamine agonist resistance or intolerance. During pregnancy, bromocriptine may be preferred due to a longer safety record, but cabergoline is acceptable. Radiotherapy is used only for treatment-refractory disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.