Galactorrhea Flashcards
What is galactorrhea?
Copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation, occuring almost exclusively in females and most commonly in adults.
In postpartum females, this also includes milk production occurring 6-12 months after pregnancy and the cessation of breastfeeding
Patrick J. Lynch, medical illustrator [CC BY 3.0], via Wikimedia Commons
Why might galactorrhea rarely be seen in male infants?
Secondary to maternal oestrogen exposure.
What is the normal physiology of lactation?
Lactation is predominantly regulated by the hormone prolactin, a polypeptide hormone which is produced and secreted by the anterior pituitary gland.
Prolactin secretion is controlled by dopamine, released by the hypothalamus, acting to inhibit prolactin secretion. Actions of TRH and oestrogen conversely act to stimulate the release of prolactin from the pituitary.
What is the most common cause of galctorrhea?
Hyperprolactinaemia
What are causes of hyperprolactinaemic galactorrhea?
- Idiopathic, occurring in around 40% cases
- Pituitary Adenoma
- Benign tumours of the pituitary gland can secrete excessive prolactin hormone, often termed prolactinomas
- Drug-Induced
- SSRIs, anti-psychotics, or H2-antagonists all stimulating prolactin release
- Neurological
- Neurogenic pathways are activated to inhibit dopamine levels, such as varicella zoster infection or spinal cord injury
- Hypothyroidism, as elevated thyrotropin-releasing hormone can also stimulate prolactin related.
- Cushing’s disease, Acromegaly, and Addison’s disease have also been associated with the condition.
- Renal failure or liver failure
- Damage to the pituitary stalk, leading to reduced dopamine inhibition to the pituitary, from surgical resection, multiple sclerosis, sarcoidosis, or tuberculosis
Discuss normoprolactinaemic galactorrhea:
- How common is it?
- What is the typical cause?
- How do you reach a diagnosis?
- How is it managed?
Less common and is typically idiopathic
Diagnosis only being made once all other causes of galactorrhoea have been excluded (i.e. normal blood markers and regular menstruation).
Typically managed with reassurance and observation
What should you ask about when taking a history from a patient with symptoms of galactorrhea?
- Determine the presence of true galactorrhoea
- Multi-ductal milky white nipple discharge, typically bilateral
- Additional symptoms
- Breast lumps
- Mastalgia
- Last menstrual period
- Features of endocrine disease & neurological symptoms (e.g. headaches, visual disturbances)
- Drug history
- Contraception, over the counter medication, or recreational drugs.
What may you find on examination of a patient with galactorrhea?
- Breast examination is often unremarkable.
- Check for any visual changes
- Suggestive of compressive pituitary masses
- Features of hypothyroidism
What investigations would you want to order for a patient with galactorrhea?
- Pregnancy test
- Serum prolactin levels
- TFTs, LFTs, and U&Es
- Further endocrine tests (e.g. IGF-1, ACTH etc.)
* If the history & examination suggests such - MRI head with contrast
* If a pituitary tumour (or parasellar pathology) is suspected, - Breast imaging
* If any palpable lumps or lymph nodes present.
What prolactin levels suggest prolactinoma?
Prolactin levels >1000 mU/L, in the absence of any drug cause
How is galactorrhea managed?
Identifying and treating the underlying cause:
- Confirmed pituitary tumours
- Dopamine agonist therapy (e.g. Cabergoline and Bromocriptine) & referred to neurosurgery for assessment for potential trans-sphenoidal surgery.
- Persisent idiopathic normoprolactinaemic galactorrhoea can be trialled with low-dose dopamine agonist.
- Troublesome galactorrhoea in patients who are intolerant of medication
- Bilateral total duct excision may be required.
