Treatment of men with sexual dysfunction and hyperprolactinemia

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The literature contains some observations of marked improvement of sexual dysfunctions associated with HPRL following non-specific treatments such as psycho- or sex-therapy [250] or, as concerns ED, sildenafil [241,253]. However, PRL-lowering dopamine-agonists (bromocriptine, lisuride, quina-golide, and cabergolide, the latter one being effective following a single administration per week) [254] most often not only normalize all aspects of sexual function, but also shrink the possible pituitary ade noma, or at least prevent its growth [18,230]. In addition, unlike PDE5-I, PRL-lowering agents allow return of sexual desire, and in the case of ED— spontaneous erections, and avoid the necessity to plan sexual intercourse. Therefore dopamine-agonists should be the first choice treatment. This therapy may not be definitive. If PRL returns within the normal range, while there is no macro-adenoma, it may be stopped every year, or every other year, for several weeks before determining the PRL level. In 20% of the cases, HPRL does not return after a number of years [255].

In the case of macro-adenoma, the patient should be referred both to an endocrinologist and to an ophthalmologist for thorough investigation of pituitary function, possible optic chiasma compression, and possible indications for its removal. This would protect the patient against tumoral complications. In case of micro-adenoma, surgical removal may be performed via the transphenoidal route, which is less damaging and may definitely cure both the tumor and the HPRL [254]. Wolfsberger etal. [256] reported on such a definitive cure in seven of 11 men with micro-adenomas. Today, however, medical therapy is more often chosen as first-line treatment [254].

In some cases, hypogonadism persists despite return to a normal PRL level, due to definitive interruption of the hypothalamic-pituitary connections or destruction of the pituitary gonadotrophs by the tumor or its surgical removal. Such patients require T substitution in addition to dopamine-agonist therapy. However, T administration may stimulate the growth of a pituitary tumor through its aromatiza-tion into estradiol if HPRL is not completely controlled by dopamine-agonist therapy, and even, more exceptionally, if it is so.

Finally, certain patients may need additional sexual counseling or therapy, especially in case of lifelong sexual dysfunction [234].

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