PMON78 Improvement in Resistant Hypogonadism with use of Clomiphene in Prolactinomas Treated with Dopamine Agonist: A Case Study and Review of Literature
Authors: Singh Julie , Penabad Jesus , Oyesanmi Olugbenga 
Published: November 2022

Abstract

Introduction
Prolactinomas account less than half of all pituitary adenomas and cause persistent hypogonadism and infertility despite treatment with dopamine agonists such as cabergoline or bromocriptine and improvement of prolactin levels (Gillam 2006). Conventional therapy for persistent hypogonadism in males is testosterone supplementation but this can cause fluctuations in serum testosterone levels and inhibition of spermatogenesis and infertility. Clomiphene citrate has been used to treat infertility and hypogonadism in males and females for over 50 years. Below we present a patient with persistent hypogonadism and review of available literature while on cabergoline with improving prolactin levels being treated with clomiphene

Case Report
A 21-year-old Caucasian male presented to our clinic after being diagnosed with macroadenoma measuring 1.6 x1.7×1.8 cm without stalk compression. Further pituitary functional work up was normal except for elevated prolactin levels of 232 ng/mL and total testosterone level of 107 ng/dL and free testosterone level of 4.1 ng/dL. Patient was started on cabergoline and titrated according to prolactin levels. Despite being on high dose cabergoline, 3.5 mg weekly, and improvement of prolactin levels (Prolactin level 53 ng/mL), he continued to have persistent hypogonadism (Total Testosterone 188 ng/dL and Free Testosterone 8.5 ng/dL) along with hypogonadal symptoms. Patient expressed his desire to preserve his future fertility and was uncertain he could use gel or self-inject replacement therapy therefore clomiphene citrate 25 mg tablet daily was started. Repeat testosterone levels six weeks later normalized (Testosterone 532 ng/dL and Free Testosterone 19 ng/dL) and symptoms improved. Treatment was continued with subsequent testosterone levels remained stable along with improved prolactin levels over the last year.

Discussion/Conclusion
A prospective study of hypogonadism in 14 males treated for prolactinomas with dopamine agonist showed 71% of patients responded to clomiphene treatment with improved testosterone levels and symptoms (Ribeiro 2009). A second study done by Vilar et al in 2018 of similar hypogonadal males on dopamine agonist treatment for prolactinomas showed 72% improvement in symptoms and testosterone levels over 12 weeks of clomiphene treatment. Our case, along with reviewed literature, showed that clomiphene is an effective alternative treatment option for resistant or persistent hypogonadism in male patients with prolactinomas being treated with dopamine agonists.

References
Gillam, M. P., Molitch, M. E., Lombardi, G., & Colao, A. (2006). Advances in the treatment of prolactinomas. Endocrine Reviews. https://doi.org/10.1210/er.2005-9998Ribeiro, R. S., & Abucham, J. (2009). Recovery of persistent hypogonadism by clomiphene in males with prolactinomas under dopamine agonist treatment. European Journal of Endocrinology, 161(1), 163–169. https://doi.org/10.1530/EJE-09-0084Vilar, L., Lyra, R., The, A. C., Trovao, E., Gadelha, P., Albuquerque, L. (2018). The role of clomiphene citrate in the resolution of hypogonadism in male patients with prolactinomas under cabergoline therapy. 20th European Congress of Endocrinology.
Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.