Galactorrhoea

Question 1

what is galactorrhoea?

Answer 1

copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation

Question 2

galactorrhoea occurs mostly in female adults but why is it occasionally seen in male infants?

Answer 2

secondary to maternal oestrogen exposure

Question 3

what regulates lactation? and where is it produced and secreted from?

Answer 3

hormone prolactin - a polypeptide hormone which is produced and secreted by the anterior pituitary gland

Question 4

what controls prolactin secretion?

Answer 4

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

Question 5

what is the most common cause of galactorrhoea?

Answer 5

hyperprolactinaemia

Question 6

what are some of the causes of hyperprolactinaemic galactorroea?

Answer 6

Idiopathic, occurring in around 40% cases

Pituitary Adenoma, whereby benign tumours of the pituitary gland can secrete excessive prolactin hormone, often termed prolactinomas

Drug-Induced, with medications such as SSRIs, anti-psychotics, or H2-antagonists all stimulating prolactin release

Neurological, whereby 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

Question 7

what diagnosis is made when all other causes of galactorrhoea have been excluded?

Answer 7

Normoprolactinaemic galactorrhoea

much less common and typically idiopathic

safely reassured and observed

Question 8

what constitutes true galactorrhoea?

Answer 8

multi-ductal milky white nipple discharge typically bilateral

Question 9

what additional features have to be identified to help with diagnosis?

Answer 9

breast lumps

mastalgia

last menstrual period

features of endocrine disease

neurological symptoms

drug Hx ie contraceptives

Question 10

what investigatios should be done?

Answer 10

exclude pregnancy

serum prolactin levels

LFT, U&Es, thyroid function tests

if history warrants - further endocrine tests

Question 11

what should be done if a pitutary tumour is suspected?

Answer 11

MRI head with contrast

Question 12

how is galactorrhoea managed?

Answer 12

identify and treat underlying cause

confirmed pituitary tumours - dopamine agonist therapy and reffered to neurosurgery for potential trans-sphenoidal surgery

idiopathic normoprolactinaemic galactorrhoea ususlly resolves spontaneously, can be trialled with low dose dopamine agonist

Question 13

how is galactorrhoea which is troublesome and intolerant to medication managed?

Answer 13

bilateral total duct excision