II. Definitions

  1. Nonpuerperal Galactorrhea
    1. Non-Lactational milk production and discharge from the Breast
    2. In addition to post-menopausal or non-lactating women (>12 months postpartum), may be seen in men and in children

III. Epidemiology

  1. Estimated lifetime Incidence in women: 20-25%

V. Differential Diagnosis

VI. History

  1. Nipple Discharge
    1. See Nipple Discharge
    2. Pathologic discharge
      1. Unilateral discharge or discharge from a single duct
      2. Bloody, serosanguineous or purulent discharge
    3. Normal discharge
      1. Galactorrhea is typically milky white, bilateral and multi-ductal
      2. Coloration can vary (yellow to brown, or even green)
      3. Precipitated by Breast stimulation
  2. Medications
    1. Oral Contraceptives are most common cause
    2. See Medication Causes of Hyperprolactinemia
  3. Gynecologic history
    1. Amenorrhea or oligomenorrha or other altered Menstrual Cycle
    2. Decreased libido
    3. Recent pregnancies, Miscarriages or abortions
  4. History in males
    1. Infertility
    2. Erectile Dysfunction
    3. Gynecomastia
  5. Past medical history
    1. Chest surgery or injury
    2. Hypothyroidism
    3. Chronic Kidney Disease
  6. Family History
    1. Multiple endocrine neoplasia (esp. Type I)
    2. Thyroid disease
  7. Social history
    1. Recent emotional stress
  8. Associated symptoms for common pathologic causes
    1. Prolactinoma
      1. Age 20 to 35 years
      2. Headache
      3. Vision change (e.g. bitemporal hemianopsia from medial Optic Chiasm compression)
      4. Seizure Disorder
      5. Polyuria or Polydypsia
    2. Hyperprolactinemia
      1. Amenorrhea
      2. Decreased libido
      3. Infertility
    3. Hypothyroidism
      1. Fatigue
      2. Cold Intolerance
      3. Constipation

VII. Examination

  1. Assess growth: Height and weight
    1. Decreased growth
      1. Hypopituitarism
      2. Hypothyroidism
      3. Chronic Renal Failure
    2. Increased growth (Acromegaly)
      1. Pituitary tumor
  2. Assess Vital Signs
    1. Bradycardia: Hypothyroidism
    2. Tachycardia: Thyrotoxicosis
  3. Chest exam
    1. Observe for local injury or infection
    2. Breast Exam (see Nipple Discharge)
  4. Associated signs for common pathologic causes
    1. Pituitary mass
      1. Visual Field deficit
      2. Papilledema
      3. Cranial Nerve dysfunction
    2. Hyperprolactinemia
      1. Hyperandrogenism (e.g. Hirsutism, Acne Vulgaris)
    3. Hypothyroidism
      1. Thyroid Goiter
      2. Myxedema
      3. Coarse hair or Dry Skin

VIII. Imaging: Brain (if indicated)

IX. Evaluation: Step 1 - Nipple Discharge

  1. Evaluate for Galactorrhea (versus other Nipple Discharge)
    1. Consider examining discharge under microscope
      1. Typically not performed, but consider if appearance is not definitive for milky discharge
      2. Sudan IV Stain will demonstrate fat globules in discharge consistent with Galactorrhea
    2. Amenorrhea present? (see history above)
      1. Galactorrhea with Amenorrhea is pathognomonic for Hyperprolactinemia
      2. Galactorrhea without Amenorrhea is associated with normal Serum Prolactin
  2. Interpretation
    1. Non-Galactorrhea
      1. Evaluate for Breast pathology
      2. See Nipple Discharge
    2. Galactorrhea
      1. Follow step 2 below

X. Evaluation: Step 2 - Galactorrhea

  1. Evaluate for physiologic Lactation
    1. Serum Prolactin rises 200 to 500 ng/ml in pregnancy
    2. Breast Feeding or delivery in the last year
    3. Obtain urine qualitative bHCG
  2. Interpretation
    1. Follow step 3 if non-physiologic Galactorrhea (negative urine bHCG and no Lactation in last year)

XI. Evaluation: Step 3 - Non-Physiologic Galactorrhea

  1. Obtain Serum Prolactin
    1. Delay measurement until at least 30 minutes or more after vigorous Exercise or Breast Exam or nipple stimulation
  2. Interpretation: Normal or decreased Serum Prolactin
    1. Idiopathic Galactorrhea
  3. Interpretation: Increased Prolactin (Hyperprolactinemia)
    1. Go to Step 4

XII. Evaluation: Step 4 - Hyperprolactinemia

  1. Tests
    1. Thyroid Stimulating Hormone (TSH) Level and Free Thyroxine
    2. Comprehensive Metabolic Panel (Electrolytes, Serum Creatinine, hepatic panel)
    3. Sex Hormones (if Hypogonadism suspected)
      1. Serum Estrogen
      2. Serum Testosterone
      3. Follicle Stimulating Hormone
      4. Luteinizing Hormone
  2. Interpretation
    1. Prolactin Level > 20 ng/ml in postmenopausal women (>30 ng/ml in premenopausal women, >18 ng/ml in men)
      1. See Hyperprolactinemia
      2. Consider MRI Pituitary (see imaging above)
    2. Hypothyroidism (TSH increased)
      1. Replace Thyroid Hormone
    3. Decreased Renal Function
      1. Evaluate for Chronic Kidney Disease
    4. Decreased liver function
      1. Evaluate for liver dysfunction
    5. Suspected Medication Causes of Hyperprolactinemia
      1. Trial medication change or discontinuation
      2. Repeat Serum Prolactin level at least 3 days after medication change
      3. If persistent Hyperprolactinemia, consider MRI Pituitary and Hyperprolactinemia evaluation
    6. Normal labs
      1. Regular Menses
        1. Observe
        2. Periodically recheck Serum Prolactin levels
      2. Amenorrhea or Oligomenorrhea
        1. Consider False NegativeProlactin seen with very large Prolactinomas (hook effect)
        2. Consider asking lab to re-run Serum Prolactin at 1:100 dilution
        3. Consider MRI Brain
        4. See Hyperprolactinemia

XIII. Management

  1. See Hyperprolactinemia
  2. Nursing pads
  3. Microadenoma with Amenorrhea and mild or manageable Galactorrhea
    1. See Hyperprolactinemia for management with Dopamine Agonists
    2. Low dose Oral Contraceptives may be considered as an alternative to Dopamine Agonists
      1. Continue Serum Prolactin level and symptom monitoring (at least yearly) and MRI pituitary as needed
  4. Microadenoma with normal Menstrual Cycles (or postmenopausal) and mild or manageable Galactorrhea
    1. Patient may choose no management (or Dopamine Agonist)
    2. Continue Serum Prolactin level and symptom monitoring (at least yearly) and MRI pituitary as needed

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