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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Hyperprolactinaemia and hypothalamic amenorrhoea

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate neurological or nutritional instability

Acute severe headache, visual loss or ophthalmoplegia may be pituitary apoplexy, while bradycardia, hypotension, orthostasis, electrolyte disturbance or syncope may reflect life-threatening energy deficiency.

Action: Use an ABCDE assessment, check glucose and electrolytes, obtain urgent cortisol and specialist pituitary input for neurological presentations, and admit medically unstable restrictive-eating or exercise-related illness.

Synopsis

Distinguish prolactin-mediated from functional hypothalamic reproductive suppression, detect pituitary and nutritional emergencies, and restore fertility, oestrogen exposure and bone health safely.

  • Both disorders suppress GnRH and can cause oligomenorrhoea, amenorrhoea, anovulation, infertility, low libido and bone loss, but their causal signals and treatment are different.
  • Confirm true prolactin excess after excluding pregnancy, lactation, stress, macroprolactin, primary hypothyroidism, renal or hepatic disease and medicines such as antipsychotics, metoclopramide, domperidone and opioids.
  • Repeat a modest prolactin under calm conditions and ask the laboratory about macroprolactin; request dilution when tumour volume is disproportionate to the reported value.
  • NICE NG257 recommends cabergoline for ovulatory disorders due to hyperprolactinaemia; the current SmPC starts 0.5 mg weekly in one or two doses with gradual specialist titration.
  • Functional hypothalamic amenorrhoea is a diagnosis of exclusion linked to low energy availability, exercise load, stress or illness and can occur at any BMI.
  • Correct energy imbalance with increased intake, reduced exercise where needed and psychological support; weight gain is often necessary, but menstruation is not the only recovery marker.
  • Do not prescribe a combined oral contraceptive solely to restore periods or improve bone density in hypothalamic amenorrhoea because it can mask recovery while energy deficit persists.
  • After a reasonable nutritional, exercise and psychological trial, specialist transdermal oestradiol with cyclic progestogen may be considered for persistent hypo-oestrogenism; fertility induction occurs only after medical and energy recovery.

    • Key red flags

    Sudden severe headache, visual loss, ophthalmoplegia, vomiting or reduced consciousness requires emergency assessment for pituitary apoplexy and cortisol deficiency.

    Progressive bitemporal field loss, diplopia or persistent headache with hyperprolactinaemia requires expedited pituitary MRI and visual assessment.

    Heart rate below 40, systolic blood pressure below 90, marked orthostasis, hypothermia, electrolyte disturbance or recurrent syncope in suspected hypothalamic amenorrhoea supports inpatient medical evaluation.

    A large sellar mass with only modest reported prolactin requires laboratory dilution to exclude the high-dose hook effect before classifying it as non-functioning.

    Clear rhinorrhoea after rapid prolactinoma shrinkage can indicate a cerebrospinal-fluid leak and needs urgent skull-base assessment.

    Investigation priorities

    01
    Repeat prolactin with macroprolactinFirst step

    Confirm persistent biologically relevant prolactin excess after reducing transient sampling effects.

    Management branches

    Raised prolactinConfirm before imaging

    Prolactin is above the laboratory range in a person with cycle disturbance.

    1. Check pregnancy, lactation, stress, chest stimulation, thyroid, renal and hepatic status and every dopamine-antagonist or opioid medicine.
    2. Repeat a modest elevation and request macroprolactin; arrange diluted assay urgently when a large sellar lesion is discordant with the concentration.
    3. Refer persistent true elevation or mass symptoms for pituitary profile, MRI, visual assessment and cause-directed endocrine care.

    Key medicines

    CabergolineStart 0.5 mg orally per week in one or two doses with food; increase the total weekly dose gradually, usually by 0.5 mg at intervals of at least one month, to the lowest effective specialist dose.Review postural hypotension, nausea, sleepiness, impulse-control or psychiatric effects and fibrotic symptoms. For long-term treatment the SmPC contraindicates pre-existing valvulopathy and requires pre-treatment echocardiography; pregnancy and subsequent cardiac monitoring follow the specialist plan and product guidance.
    Transdermal oestradiol with cyclic progesteroneAfter a recovery trial, the specialist may use a 17β-oestradiol patch in a physiological replacement dose with oral micronised progesterone 200 mg nightly for 12–14 days each 28-day cycle.This does not correct the energy deficit or provide reliable contraception; protect every intact uterus, investigate abnormal bleeding and individualise thrombotic, cancer and liver risk.
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    Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG257 female fertility management
    • Cabergoline UK SmPC
    • Endocrine Society hypothalamic amenorrhoea guideline
    • NICE eating disorders guidance
    • University Hospitals Sussex cabergoline information

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom