TOC  |  ENDO

*GALACTORRHEA / HYPERPROLACTINEMIA

Milky nipple discharge. Galactorrhea technically does not include serous, purulent, or bloody nipple discharge.

SX:

• Milky nipple discharge.
• May also have signs/symptoms of associated conditions (e.g., hypothyroidism, Cushing's disease, acromegaly, fibrocystic breast disease)
• May also have signs/symptoms of pituitary enlargement (e.g., headache, visual field loss)

CAUSES:

1. Physiologic (pregnancy and up to 6 months after delivery or after stopping breast-feeding)
2. Prolactin producing pituitary adenoma
3. Medications (e.g., opioids, tricyclics, metoclopramide, verapamil, phenothiazines, alpha-methyldopa, isoniazid, estrogens, reserpine, butyrophenones)
4. Oral contraceptive pill withdrawal
5. Hypothyroidism
6. Chest wall conditions (e.g., herpes zoster, post-thoracotomy, fibrocystic breast changes)
7. Postoperative state (any major surgery, but especially oophorectomy)
8. Chiari-Frommel (idiopathic galactorrhea more than 6 months postpartum)
9. Idiopathic
10. Miscellaneous causes (e.g., sarcoid, renal failure, Cushing's disease, cirrhosis, head trauma, lupus, multiple sclerosis or other pituitary or hypothalamic disease)

DIFF-DX:

• Non-milky discharge (e.g., serous) - consider fibrocystic disease
• Purulent discharge - consider mastitis
• Bloody discharge - rule out breast malignancy

LAB:

• Blood Prolactine, BUN, Creat, LFT, TSH, FSH/LH, pregnancy test
• Check growth hormone (GH) and adrenal steroids, if clinically suspect acromegaly or Cushing's disease

SPECIAL TESTS: Formal visual field testing if pituitary adenoma suspected

IMAGING:

• Pituitary MRI or CT scanif prolactin even minimally elevated, or if any other reason to suspect pituitary disease clinically

RX:

• Treat underlying causes as indicated; galactorrhea by itself is not harmful
• Other reasons to treat include symptom management (if symptoms cause patient anxiety), fertility restoration (if amenorrheic), to cause growth retardation or regression of adenoma, or to prevent osteoporosis (if estrogen deficient)
• "Watchful waiting" is often most appropriate
• Discontinue offending medications, if any
• Pituitary macroadenomas (tumors 10 mm size) warrant treatment even if asymptomatic

SURGICAL MEASURES

Large adenomas may be treated with x-ray therapy (variable success, 50% risk of panhyperpituitarism at 5 years) or transsphenoidal adenoma removal (variable success, recurrence common)

Ref:
Dambro: Griffith's 5-Minute Clinical Consult, 1999

1. Failure of normal hypothalamic inhibition of prolactin release

• Pituitary stalk section
• Drugs: haloperidol, chlorpromazine, estrogen, etc.
• CNS disease

2. Enhanced prolactin releasing factor: Hypothyroidism

3. Enhanced prolactin release independent of normal mechanisms

a. Pituitary tumors

1. Prolactin secreting tumors (Forbes Albright's syndrome)
2. Mixed growth hormone & prolactin

b. Ectopic production of human placental lactogen & prolactin

1. Hydatidiform moles & chorioepitheliomas
2. Others (bronchogenic Ca & hypernephroma)

4. Idiopathic (following or not following pregnancy or contraceptions)

HYPERPROLACTINEMIA CAUSES:

1. Physiologic: Pregnancy, Stress (e.g. surgery), suckling, sexual intercourse, sleep, exercise, meals

2. Pharmacologic: various drugs (e.g. chlorpromazine, haloperidol), oral contraceptives, estrogens, thyrotropin releasing hormone, parathyroid hormone, insulin induced hypoglycemia, arginine

3. Pathologic:

• Idiopathic hyperprolactinemia
• Pituitary tumors
• Pituitary stalk section
• Hypothalamic disorders (e.g. sarcoid infiltration)
• Hypothyroidism
• Chiari Frommel syndrome
• Nelson's syndrome  -  Enlargement of occult ACTH producing pituitary tumors following adrenaclectomy for Cushing's disease.
• Renal failure

04122001