Galactorrhea
Julie Adkins, Jill C. Cash, Mellisa A. Hall, Cheryl A. Glass, Angelito Tacderas, and Jenny Nelson Mullen
Definition
A.The production of a milky discharge excreted from the nipple, occurring beyond the 6-month period of pregnancy and/or breastfeeding cessation.
Incidence
A.It is estimated that 1% to 50% of reproductive women will experience galactorrhea at some time in their life.
Pathogenesis
A.The pathogenesis depends on the etiology. Physiologic galactorrhea is caused by pregnancy. The anterior pituitary gland secretes prolactin, which stimulates milk production. Milk production is normal for 6 months after pregnancy and/or after breastfeeding has ceased. The majority of cases are from benign etiology. Malignancy is responsible for 5% to 10% of cases.
Predisposing Factors
A.Reproductive women.
B.Medications: Oral contraceptions, pimozide, risperidone, molindone, olanzapine, clomipramine, desipramine, haloperidol (Haldol), metoclopramide (Reglan), cimetidine, Isoniazid, (Aldomet), reserpine, verapamil, codeine, morphine, and imipramine (Tofranil).
C.Lesions involving chest wall: Breast surgery, burns, herpes zoster, spinal cord injury, trauma.
Common Complaints
A.Milky discharge from the nipple.
Subjective Data
A.Note the onset, duration, and course of presenting symptoms.
B.Ask whether the patient has been pregnant and/or breastfed within the past 6 months. If so, how long did she nurse?
C.Review her menstrual history and pattern.
D.Ask her to describe the discharge, noting color, consistency, and/or presence of blood.
E.Determine the mechanism of production of discharge: Spontaneous or with manual expression.
F.Assess for any palpable mass in the breast.
G.Review current medications, including use of oral contraceptives.
H.Note any previous experience with galactorrhea. If so, discuss testing performed and treatment, if any.
I.Identify any family history of breast cancer or other tumors.
Physical Examination
A.Check pulse, respirations, and blood pressure (blood pressure).
B.Inspect:
1.Inspect the breast.
2.Assess the discharge.
3.Inspect the skin; note dimpling, retraction, and irregularities.
4.Eyes: Complete funduscopic examination.
5.Perform visual field testing.
C.Palpate:
1.Palpate the breasts for masses and fibrocystic changes.
2.Squeeze the nipple to induce discharge.
3.Palpate the axillary lymph nodes.
4.Palpate the neck, thyroid, and lymph nodes.
Diagnostic Tests
A.Prolactin level: Normal level is 1 to 20 ng/mL.
B.Thyroid-stimulating hormone (TSH).
Many cases of galactorrhea are considered idiopathic. Usually endocrine studies will be normal.
C.Beta human chorionic gonadotropin (beta HCG).
D.Hemoccult of breast discharge.
E.Breast discharge for pathology.
F.Periareolar ultrasound (all ages).
G.CT/MRI of sella turcica if pituitary mass is suspected.
H.Mammogram in women older than 30 years if tumor is suspected.
I.Ductoscopy.
J.Skin punch biopsy for abnormal skin presentations.
Differential Diagnoses
A.Galactorrhea.
B.Fibrocystic disease.
C.Mastitis.
D.Breast tumor.
E.Medication induction.
F.Breast cancer: Bloody nipple discharge, painless, firm fixed mass.
G.Pituitary adenoma: Can produce permanent visual field loss and headaches.
H.Hypothalamic disorders.
I.Chiari-Frommel: Galactorrhea occurring after 6 months postpartum.
J.Pituitary and thyroid disorders.
K.Renal insufficiency a result of decreased clearance of prolactin.
Plan
A.General interventions:
1.Treat underlying cause of nipple discharge.
2.If induced by medications, consider stopping medications if side effect outweighs benefits.
3.If benign cause, no treatment is necessary with medication. Monitor symptoms. If symptoms progress, reevaluate.
B.Patient teaching:
1.Teach self-examination of the breast.
C.Pharmaceutical therapy:
1.No pharmaceuticals are advised when tapering or discontinuing medications that are causing the discharge. This is recommended only after cautious consideration of why the medication is being used (antipsychotics).
2.American Academy of Family Physicians (AAFP) recommends if galactorrhea is caused by hyperprolactinemia and/or prolactinoma:
a.First choice medication use is cabergoline because it is considered to be more effective and better tolerated. Cabergoline 0.25 to 1 mg twice a week, or 0.5 to 2 mg once a week. Discontinue once pregnancy is confirmed.
b.Second choice is Bromocriptine 2.5 to 15 mg daily. It is lower cost yet higher incidence of side effects. Discontinue once pregnancy is confirmed.
Follow-Up
A.Monitor prolactin level every 6 to 12 months.
B.Recommend yearly vision evaluation.
C.Order MRI at 1 year, then every 2 to 5 years if symptoms persist.
Consultation/Referral
A.Consult a physician regardless of normal imaging results if breast tumor is suspected with bloody discharge or palpable mass noted.
Individual Considerations
A.Pregnancy:
1.Galactorrhea during pregnancy is a normal physiologic response.
2.If galactorrhea persists after pregnancy/lactation has ceased for 6 months, a full workup evaluation is required.
B.Adults:
1.Men: Galactorrhea is rare in men; however, it can occur with prolactinoma.
C.Geriatrics:
1.Causes of galactorrhea include antipsychotic medications, renal insufficiency, or pituitary/hypothalamus disorders impairing dopamine secretion.