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Galactorrhea

BASICS

  • Milky nipple discharge not related to breastfeeding, occurring >1 year after pregnancy or cessation of lactation.
  • Excludes serous, purulent, or bloody discharges.
  • Systems: endocrine/metabolic, nervous, reproductive.

EPIDEMIOLOGY

  • Common in reproductive age women (15-50 years), mostly 20-35 years.
  • Third most common breast complaint.
  • Lifetime prevalence 20-25%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Oxytocin stimulates prolactin secretion from anterior pituitary, inducing lactation.
  • Prolactin inhibited by hypothalamic dopamine; galactorrhea results from excess prolactin or dopamine inhibition loss.
  • Physiologic causes: pregnancy, nipple stimulation, exercise, sexual activity.
  • Pathologic hyperprolactinemia causes: prolactinoma (most common), hypothyroidism, renal failure, cirrhosis, adrenal insufficiency.
  • Medications: dopamine antagonists or suppressants (antipsychotics, SSRIs, antiemetics, opioids, etc.), herbal supplements (anise, fenugreek), illicit drugs (cocaine, marijuana).

GENERAL PREVENTION

  • Avoid frequent nipple stimulation.
  • Avoid medications that suppress dopamine.

COMMONLY ASSOCIATED CONDITIONS

  • Hypothyroidism, chronic kidney disease, hypogonadism, pituitary adenoma.
  • Rarely adrenal insufficiency, chest wall trauma, acromegaly.

DIAGNOSIS

History

  • Bilateral milky discharge, spontaneous or stimulation-induced.
  • Pregnancy or recent breastfeeding cessation.
  • Medication/supplement history.
  • Symptoms of hypogonadism (amenorrhea, infertility, decreased libido).
  • Mass effect symptoms (headache, visual changes).

Physical Exam

  • Breast exam for nipple discharge.
  • Visual field testing if pituitary tumor suspected.

Differential Diagnosis

  • Physiologic lactation, recent weaning.
  • Nonmilky discharge causes (papilloma, fibrocystic disease).
  • Purulent (mastitis, abscess).
  • Bloody discharge (Paget disease, malignancy).

DIAGNOSTIC TESTS & INTERPRETATION

  • Urine hCG to rule out pregnancy.
  • Serum prolactin: normal <30 ng/mL (nonpregnant); elevated >200 ng/mL suggests prolactinoma.
  • Confirm elevated prolactin with fasting, no nipple stimulation.
  • Evaluate thyroid, liver, renal function.
  • Imaging: Pituitary MRI with gadolinium if prolactin elevated or tumor suspected.
  • Consider FSH, LH if amenorrhea; growth hormone if acromegaly; adrenal steroids if Cushing's suspected.

TREATMENT

General Measures

  • Treat underlying cause.
  • Idiopathic galactorrhea with normal prolactin usually no treatment.
  • Avoid nipple stimulation and causative drugs.
  • Nursing pads for symptom management.

Medication

  • Dopamine agonists first line: cabergoline preferred (0.25 mg twice weekly, titrate up).
  • Bromocriptine second line (start 1.25 mg QHS, titrate).
  • Monitor prolactin monthly until normalized, then quarterly during treatment.
  • Discontinue dopamine agonists if pregnancy occurs.
  • Contraindications: uncontrolled hypertension, ergot sensitivity.

ISSUES FOR REFERRAL

  • Endocrinology, neurology, breast surgery based on etiology.

SURGERY/OTHER PROCEDURES

  • Consider surgery or radiotherapy if tumor >10 mm or refractory.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Anecdotal: peppermint, parsley, sage ingestion; topical cabbage leaves for milk suppression.

ONGOING CARE

  • Regular prolactin monitoring during and after therapy.
  • Annual visual field and MRI if prolactinoma.

DIET

  • No restrictions; may include herbal remedies.

PATIENT EDUCATION

  • Educate on symptoms of pituitary tumor enlargement (vision changes, headache).
  • Inform on medication effects and pregnancy considerations.
  • Educate new mothers on normal infant galactorrhea due to maternal hormones.

PROGNOSIS

  • Recurrence possible after stopping therapy.
  • Macroadenoma surgery recurrence ~50%.
  • Microadenomas (<10 mm) may spontaneously remit.
  • Persistent amenorrhea may lead to osteoporosis.
  • Hyperprolactinemia not linked to breast cancer risk.

COMPLICATIONS

  • Visual field loss from tumor growth.
  • Osteoporosis from prolonged amenorrhea.

REFERENCES

  1. Majumdar A, Mangal NS. Hyperprolactinemia. J Hum Reprod Sci. 2013;6(3):168-175.
  2. Huang W, Molitch ME. Evaluation and management of galactorrhea. Am Fam Physician. 2012;85(11):1073-1080.
  3. Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an Endocrine Society Clinical Practice guideline. J Clin Endocrinol Metab. 2011;96(2):273-288.

CODES

  • ICD10: N64.3 Galactorrhea not associated with childbirth
  • ICD10: N64.52 Nipple discharge

CLINICAL PEARLS

  • Galactorrhea affects up to 50% of reproductive-aged women.
  • Bilateral milky discharge is typical; variations exist.
  • Common causes: idiopathic, nipple stimulation, dopamine-suppressing drugs, systemic diseases, prolactinoma.
  • Prolactin >200 ng/mL or macroadenoma suspicion warrants pituitary MRI.
  • Cabergoline is first-line medication; bromocriptine is second-line.