LM 19.1: Galactorrhea Flashcards
what is galactorrhea?
breast milk production outside the context of normal lactation
what are the causes of galactorrhea?
- physiologic and occur because of nipple stimulation (breast feeding)
- elevated prolactin levels
- pathologic manifestation of anterior pituitary tumor
- side effects of durgs
- occur in patients with CKD who can’t clear serum prolactin
- hypothyroidism
is galactorrhea associated with malignancy?
not associated with malignancy, but it must be distinguished from other types of breast secretions / pathology that may be associated with malignancy
where is prolactin secreted from?
anterior pituitary gland
what does prolactin do?
- can stimulate milk production in females
- can stimulate milk production in males with pituitary tumors or gynecomastia
- inhibits the synthesis and release of GnRH
can you have galactorrhea with normal prolactin levels?
yes!
what is a pituitary adenoma?
a benign tumor of the pituitary gland
can cause hyperprolactinemia
can be “non-functional” or “functional”
what are non-functional pituitary adenomas?
- do not alter hormone levels
- cause symptoms due to its size/mass
- compress pituitary tissue and decrease pituitary function
what are functional pituitary adenomas?
they DO alter hormone levels
may cause elevated prolactin and inhibit GnRH synthesis
what happens when there is hyperprolactinemia in women?
hyperprolactinemia results in decreased production of GnRH
decreased GnRH leads to decreased production of FSH and LH
decreased FSH and LH can result in a lack of ovulation and amenorrhea
functional pituitary adenomas in females can result in amenorrhea since elevated prolactin levels inhibit GnRH synthesis, leading to decreased FSH and LH, thus inhibiting ovulation.
how does galactorrhea effect males?
decreased GnRH synthesis inhibits spermatogenesis
men with galactorrhea often experience decreased libido
not common in males unless androgen levels are low and gynecomastia is presen
how would a patient with galactorrhea present?
women present with galactorrhea more often than men
patients normally present with bilateral breast secretions
it is crucial to take a thorough patient history; ask about the patient’s breast discharge: –> unilateral/bilater, color, timing
what questions should you ask during a history for a patient presenting with galactorrhea?
- is the discharge unilateral or bilateral?
- what color is the discharge?
- does the discharge occur when the breasts are physically stimulated
- has the patient has su ered a chest wall injury? (This can induce hyperprolactinemia and therefore galactorrhea.)
- do females have menstrual cycle abnormalities or other signs of hypogonadism?
- are females experiencing any hot ashes or vaginal dryness?
- is the patient taking any medication/supplements?
- does the patient have any signs of decreased energy, libido, headaches, or visual changes?
how do pre-menopausal women with galactorrhea present?
low GnRH can lead to low FSH and LH
low FSH and LH can result in oligomenorrhea, amenorrhea, infertility and/or galactorrhea
how do post-menopausal women with galactorrhea present?
are already in a hypogonadal state, so they do not notice changes such as amenorrhea, oligomenorrhea, or infertility
low estrogen state makes galactorrhea less likely to occur
what is a common presentation of pituitary adenoma?
pituitary adenoma can exert a mass e ect if it is large enough
since the mass would be located in the sella turcica region, it can compress the optic chiasm
any patient with a large enough pituitary adenoma (whether they are pre-menopausal or post-menopausal) may present with headache and/or bitemporal hemianopsia due to mass e ect
what is the most common cause of galactorrhea in men?
most likely to occur in men with hyperprolactinemia due to pituitary tumors and gynecomastia
if galactorrhea was triggered by hyperprolactinemia, they may also present with Erectile Dysfunction (ED) – if the hyperprolacinemia is treated, the ED can be reversed
hyperprolactinemia can cause decreased testosterone secretion and therefore, hypogonadotropic hypogonadism
males may initially present with decreased energy and decreased libido
over the long term, males with hyperprolactinemia may have decreased muscle mass, decreased body hair, osteoporosis, and infertility due to decreased FSH and LH
how can we distinguish various types of breast discharge?
only approximately 5% of women with breast cancer present with breast discharge but if breast discharge is present, the type of discharge should be determined
galctorrhea is a benign condition, but other forms of breast discharge may suggest malignancy
galactorrhea can appear clear, milky, green, or black
galactorrhea normally causes bilateral secretions
ig the discharge contains fat, milk production (galactorrhea) is con rmed
if the discharge contains blood, consider other possibilities
what are the red flags of breast discharge that suggest malignancy?
- unilateral, occurs spontaneously, and is persistent
- serous, serosanguinous, or bloody
- present along with a breast lump/mass
- present in elderly patients
symptoms that suggest benign galactorrhea: milky breast discharge, bilateral discharge, green breast discharge
which medications can induce galactorrhea?
- antipsychotic medications such as: Haloperidol, Loxitane, Mellaril, Moban, Navane, Prolixin, Risperidone, Stelazine, Thioxanthenes, Thorazine, Trilafon
- anti-anxiety drugs including: Benzodiazepines, Buspirone
- anti-depressant medications including: Monoamine Oxidase Inhibitors (MAOIs), Selective Serotonin Receptor Inhibitors (SSRIs), and Tricyclic Antidepressants
Neurological medications including: Dihydroergotamine, Sumatriptan, Valproic Acid - gastrointestinal agents including: Histamine 2 blockers (Cimetidine, Famotidine, Ranitidine) and Metoclopramide
- hormonal Preparations including: Danazol, estrogen, medroxyprogesterone acetate, oral contraceptives
- controlled Substances/Illicit Drugs including: Amphetamines, cannabis, cocaine, opiates
- Anti-hypertensive medications including: Atenolol, methyldopa, reserpine, verapamil Source: Smith, MA; Schrager, S.; Winkler Prins, V. Matus, C. Speer, L.
Essentials of Family Medicine. 7th ed. Women’s Health. Wolfers Kluwer. 2018.
what testing should be done for galactorrhea?
- if a patient presents with galactorrhea and no breast mass, measure serum prolactin
- normal prolactin: 5 to 20 ng/mL in women and 2 to 18 ng/mL in men
- best to obtain the blood sample when the patient is fasting
- strenuous exercise, sleep, and physical/emotional stress can raise serum prolactin levels
patients with elevated prolactin levels should undergo MRI of the hypothalamic/pituitary region with contract –> if a mass if found other hormone levels should be assessed
what do you do if someone has serious, serosanguinous or bloody discharge?
other breast pathology may be present, including the possibility of breast malignancy
imaging should be performed:
- ultrasound = Initial imaging modality of choice for women with a breast
mass under age 30 - mammography = Initial imaging modality of choice for women with a breast mass over age 30
how do you treat galactorrhea due to hyperprolactinemia?
- prevent neurological complications that could arise due to a pituitary adenoma
- treat hypogonadism
- alleviate bothersome symptoms of galactorrhea
what is a pituitary macro adenoma vs. microadenoma?
macroadenomas
1. 1 cm or more in diameter
- serum prolactin usually over 200 ng/mL
microadenomas
1. less than 1 cm in diameter
- serum prolactin levels under 200 ng/mL
what is the medical treatment of pituitary adenomas?
- dopamine agonists
medication class used to treat pituitary adenomas and hyperprolactinemia.
- cabergoline
1st choice dopamine agonist for most patients with hyperprolactinemia –> efficacious and less side effects than bromocriptine but increased risk of valvular heart disease at high doses
- bromocriptine
2nd choice dopamine agonist for patients with hyperprolactinemia
more likely to cause nausea than Cabergoline
if women with a lactotroph adenoma desire pregnancy but their prolactin levels do not reach normal levels, how do you induce ovulation?
dopamine agonist therapy like Clomiphene Citrate or Gonadotropin
what are the surgical managements of pituitary adenomas?
transphenoidal surgery could be performed to treat a macro adenoma
but this is reserved only for when:
1. prolactinoma does not decrease in size after medical treatment
- symptoms do not improve after several months of high-dose medical therapy
- a woman has a lactotroph adenoma larger than 3 cm in diameter and desires pregnancy
how can radiation be used to treat pituitary adenoma?
radiation may be used after surgery in an attempt to prevent tumor recurrence
what are the complications associated with radiation treatment for pituitary adenomas?
- nerve damage
- nausea
- hair loss
- 50% chance anterior pituitary hormone secretion will be lost within 10 years of radiation
what is the general class of medication used to treat pituitary adenoma or hyperprolactinemia?
dopamine agonists
1st line medication used to treat pituitary adenoma or hyperprolactinemia
cabergoline
2nd line medication used to treat pituitary adenoma or hyperprolactinemia
bromocriptine
how do you treat galatorrhea that doesn’t have hyperprolactinemia?
it doesn’t require treatment
however, if symptoms are bothersome it can be treated with a dopamine agonists like cabergoline
A 28 year-old female visits her primary care doctor. Her blood pressure is 115/70, HR is 70, and her BMI is 21.2. She has no previous substantial medical history and denies taking any medications, supplements, alcohol, or illicit drugs. Over the past few months, her menstrual cycles have been irregular. She has also experienced bilateral discharge from her breasts that has soaked through her bra. A breast examination is performed. There are no palpable masses, but white discharge emerges from both nipples on examination. If her beta human chorionic gonadotropin test is negative and her prolactin levels are at 227ng/mL, which test would be most appropriate to order next?
MRI of the pituitary/hypothalamic region with contract
she has menstrual irregularities, bilateral galactorrhea, and an elevated prolactin level of 227ng/mL – she most likely has a pituitary adenoma in the sella turica region
MRI of the hypothalamaus/pituitary with contrast would provide the best chance of discerning a pituitary adenoma.
mammography is not be necessary because she is 28 years old (it should not be performed in women under 30) and because her clinical presentation and lab results do not suggest the possibility of malignancy or other breast mass
no need to perform a bilateral biopsy for galactorrhea induced by hyperprolactinemia
A 32 year old woman presents to her primary care physician because she has had bilateral nipple discharge over the past couple of months. The discharge appears white and milky. Her periods used to occur regularly, but have been “more sporadic” over the past few months. She denies any vision changes, headaches, hirsutism, acne, weight gain, or male pattern baldness. Her current medications include insulin, risperidone, and a combined calcium and vitamin D supplement. what is the most likely cause of her bilateral nipple discharge?
risperidone
risperidone is an anti-psychotic medication that has been commonly associated with increased prolactin levels, galactorrhea, and also irregular periods
PCOS can cause menstrual cycle irregularities, this patient denies hirsutism, acne, weight gain, or male pattern baldness
