A 35-year-old man presents with progressive headache, bitemporal hemianopia, and erectile dysfunction. MRI brain shows a 2 cm sellar mass with suprasellar extension. Serum prolactin is 180 ng/mL (normal <25 ng/mL). Which is the most appropriate first-line management?

Explanation

## Prolactinoma Management This patient has a **macroprolactinoma** (>1 cm, prolactin >200 ng/mL) with mass effect (headache, bitemporal hemianopia). **Key Point:** Dopamine agonists (bromocriptine, cabergoline) are the first-line treatment for prolactinomas, even with mass effect, because: - Dopamine suppresses prolactin secretion - Causes tumor shrinkage in >90% of cases - Improves visual fields and headache - Surgery reserved for dopamine agonist resistance or intolerance **Clinical Pearl:** Cabergoline is preferred over bromocriptine due to better tolerability, higher efficacy, and less frequent dosing (twice weekly vs. 2–3 times daily). **High-Yield:** Macroprolactinomas respond dramatically to medical therapy; surgery is not first-line unless there is acute visual loss or apoplexy.