A 39-year-old lady with a 15mm tumor in the pituitary fossa has not responded to cabergoline for her prolactinoma. What is the most appropriate management?

In the scenario described, the most appropriate management for a 39-year-old woman with a prolactinoma that has not responded to cabergoline, particularly given the presence of a tumor in the pituitary fossa, is transsphenoidal surgery.

Transsphenoidal surgery is the standard approach for treating pituitary tumors, especially when medication fails to control the disease effectively. This minimally invasive surgical technique allows for direct access to the pituitary gland through the sphenoid sinus, which is beneficial in both diagnosing and treating prolactinomas or other pituitary tumors. The goal of the surgery is to remove the tumor, which helps alleviate symptoms caused by excessive prolactin and reduces the mass effect on surrounding structures, potentially restoring normal pituitary function.

In this case, since the tumor was not responsive to cabergoline—a dopamine agonist commonly used for managing prolactinomas—indicating a surgical intervention might have a better chance of resolution is essential. Octreotide is typically not effective in treating prolactinomas; it is more commonly used for other neuroendocrine tumors. Radiotherapy may be considered in certain situations, particularly if there are remaining tumor remnants after surgical resection or if the tumor is determined to