Galactorrhea

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Chapter 14 GALACTORRHEA

Theodore O’Connell

Galactorrhea is the inappropriate production of milk from the breast in the absence of pregnancy or beyond 6 to 12 months post partum in a nonbreastfeeding woman. The discharge of milk may be unilateral or bilateral, may be intermittent or persistent, and may vary in volume. Galactorrhea may also occur in boys and men and in infants and teenage girls.

Distinguishing galactorrhea from other forms of nipple discharge is usually straightforward. In galactorrhea, the discharge has the appearance of milk, occurs from multiple ducts in the nipple, most commonly occurs bilaterally, and is usually spontaneous.

When nipple discharge is consistent with galactorrhea, the medical history often reveals the cause. Important elements of the history and physical examination are outlined in the following sections.

Key Historical Features

✓ Duration of galactorrhea

✓ Unilateral or bilateral presence

✓ Associated mass

✓ Medications

✓ Medical history, particularly thyroid disorders or renal failure

✓ Surgical history, especially recent chest surgery

✓ Family history, especially thyroid disorders or multiple endocrine neoplasia, which increase the risk for galactorrhea

✓ Reproductive history

• Oral contraceptives, the most common medication-related cause of galactorrhea

• Oligomenorrhea, amenorrhea, infertility, or decreased libido, suggestive of hyperprolactinemia

• Amenorrhea, which may indicate pregnancy or pituitary tumor

✓ Constitutional symptoms

• Fatigue and cold intolerance, suggestive of hypothyroidism

• Nervousness, heat intolerance, unusual sweating, and weight loss despite a normal or increased appetite, suggestive of thyrotoxicosis

• Polyuria and polydipsia, suggestive of pituitary or hypothalamic disease

✓ Skin symptoms

• Dry skin, suggestive of hypothyroidism

• Acne and hirsutism, suggestive of hyperandrogenism

✓ Gastrointestinal symptoms

• Constipation, suggestive of hypothyroidism

✓ Neurologic symptoms

• Headache, visual disturbance, and seizure, suggestive of pituitary or hypothalamic disease

Key Physical Findings

✓ Vital signs

✓ Poor growth or short stature, suggestive of hypothyroidism, hypopituitarism, or chronic renal failure

✓ Acromegaly or gigantism, suggestive of pituitary tumor

✓ Breast examination for nodules and discharge and determination of whether the discharge is from one or multiple ducts

✓ Cardiac examination for bradycardia suggestive of hypothyroidism or tachycardia suggestive of thyrotoxicosis

✓ Skin examination for dry skin, coarse hair, and myxedema, suggestive of hypothyroidism, or for hirsutism and acne, suggestive of hyperandrogenism

✓ Head and neck examination for goiter, suggestive of hypothyroidism

✓ Eye examination for visual field defect or papilledema, suggestive of pituitary tumor or intracranial mass

✓ Neurologic examination for hand tremor, suggestive of thyrotoxicosis, or for a cranial neuropathy, suggestive of pituitary tumor or intracranial mass

Suggested Work-Up

The evaluation of galactorrhea should proceed in a stepwise manner and be guided by findings from the history and physical examination.

Pregnancy test	To evaluate for pregnancy in women of childbearing age
Serum prolactin measurement	To evaluate for pituitary adenoma
Thyroid-stimulating hormone (TSH)	To evaluate for hypo- or hyperthyroidism

Additional Work-Up

If hyperprolactinemia is confirmed, medications that may cause elevation in prolactin levels should be withheld if possible. The prolactin level should then be measured again.

If true hyperprolactinemia is found, magnetic resonance imaging (MRI) with gadolinium enhancement should be performed to evaluate the pituitary fossa. A serum prolactin level greater than 200 ng/mL is strongly suggestive of pituitary adenoma.

Other recommended testing is as follows:

Measurement of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and dehydroepiandrosterone sulfate (DHEAS) levels	To evaluate for hyperandrogenism when it is suggested by history and physical examination
Measurement of blood urea nitrogen (BUN) and creatinine levels	When chronic renal failure is suggested by history and physical examination
MRI of brain with gadolinium	When intracranial mass is suggested by history and physical examination

FURTHER READING

Benjamin F. Normal lactation and galactorrhea. Clin Obstet Gynecol. 1994;37:887-897.

Falkenberry SS. Nipple discharge. Obstet Gynecol Clin. 2002;29:21-29.

Jardines L. Management of nipple discharge. Am Surg. 1996;62:119-122.

Leung AKC, Pacaud D. Diagnosis and management of galactorrhea. Am Fam Physician. 2004;70:543-550.

Luciano AA. Clinical presentation of hyperprolactinemia. J Reprod Med. 1999;44(12 Suppl):1085-1090.

Serri O, Chik CL, Ur E, et al. Diagnosis and management of hyperprolactinemia. CMAJ. 2003;169:575-581.

Spack NP, Neinstein LS. Galactorrhea. In: Neinstein LS, editor. Adolescent Health Care: A Practical Guide. 4th. Philadelphia: Lippincott Williams & Wilkins; 2002:1045-1051.

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