Galactorrhea

Question 1

What are two medications that may cause mild to moderate hyperprolactinemia?

Answer 1

Dopamine receptor antagonists:
Antipsychotics
Antiemetics (metoclopramide, domperidone)

Other:
Methyldopa
SSRIs
TCAs
High-dose androgens or estrogens
Opiates
Verapamil

Question 2

Prolactin is necessary but not sufficient for galactorrhea. What other hormone(s) must be present?

Answer 2

Estrogen

Progesterone

Question 3

“I weaned my son six months ago, yet I still notice some milk production with nipple stimulation. Do I need any tests done? Could this be serious?”

Answer 3

No - physiologic galactorrhea may persist up to 1 year post lactation

Question 4

How can you distinguish true galactorrhea from white breast discharge?

Answer 4

Fat globules on microscopy

Question 5

What follow-up testing should be performed if a patient has a large pituitary tumour, but prolactin is only mildly elevated? Why might this be?

Answer 5

Serial dilutions - level may be falsely low due to prolactin saturating the test (“hook effect”)
Levels of all pituitary hormones - tumour may not be a prolactinoma, but simply causing hyperprolactinemia due to mass effect on the pituitary stalk

Question 6

Under what circumstances might it be reasonable not to treat idiopathic hyperprolactinemia?

Answer 6

Patients not wishing conception, not distressed by galactorrhea (if present), without evidence of hypogonadism

Question 7

What is the major complication associated with surgery for prolactinomas?

Answer 7

Panhypopituitarism

Question 8

Under what circumstances should dopamine agonists be continued in pregnancy?

Answer 8

If a macroadenoma is present

Recommend discontinuing otherwise, although there is no evidence of teratogenicity